September 23, 2020

What We Got Wrong


            To date, 68,000 residents and staff of nursing homes and other long-term care facilities have died from COVID-19, accounting for a significant proportion of U.S. pandemic deaths. According to the editorial board of the NY Times, “…many, if not most of those 68,000 lives could have been spared with careful planning and effective leadership.” There is little doubt that poor management and unwise decision-making, sometimes driven by cost considerations, exacerbated what was already a highly flammable situation. Putting a large number of very old people with multiple underlying health conditions together and then sending in caregivers who live in communities with high rates of coronavirus is asking for trouble. But to blame for-profit chains for the devastation wrought by COVID-19 in nursing homes, as the NY Times does, is missing the forest for the trees. It is like blaming the forest fires raging throughout the western U.S. on gas companies that had not cleaned up the dry brush near their power lines while ignoring the role of climate change and of urbanization that have brought hotter, dryer conditions and dense human habitation in close proximity to forested areas, respectively. A recent article in the New England Journal of Medicine gets it right, suggesting that “the coronavirus has exposed and amplified a longstanding and larger problem: our failure to value and invest in a safe and effective long-term care system.” 

            The problem began, as Rachel Werner and colleagues from the University of Pennsylvania argue, with the Medicare and Medicaid legislation of 1965, which effectively medicalized long-term care. Long-term care refers to services that help people get by when they cannot perform everyday activities independently; it encompasses housing, personal care, and medical care. By placing almost all government support for the social and daily care needs of frail older individuals under a medical umbrella, the non-medical needs were given short shrift and the medical needs were under-funded. 

            I’m talking about frailty because it’s frail older people who are the main users of long-term care. Frailty refers to a syndrome of age-associated loss of independent functioning that puts people at risk of illness, decline, and death. Frail people constitute about 15 percent of the elderly population or 8 million people. Most frail elders continue to live in their own homes and get help from caregivers; about one million live in an assisted living facility, where they have their own apartment but eat meals communally, receive a small amount of personal care each day, and can participate in on-site social activities; another 1.3 million live long-term in a nursing home. How does the prevailing long-term care system in the U.S. operate and how do Medicare and Medicaid determine its contours?

            In terms of housing, because Medicare and Medicaid are medical programs, they were not designed to cover housing. Medicare does not pay for housing at all: it will pay for short-term “post-acute care” after a hospitalization, either in a rehabilitation facility or a skilled nursing facility because that is viewed as hospital care. Medicare does not pay for long-term residential nursing home care or residential hospice care—it will cover medical care received by an individual who lives in a nursing home or a hospice, just as it covers doctor’s visits and laboratory tests for a person who lives independently in his own home. Medicaid pays for nursing home care for individuals who have “spent down” all their assets and are sufficiently physically impaired to require nursing home in a rare acknowledgement that the line between housing, personal care, and medical care is blurred for frail older individuals.

            With respect to personal care, Medicare provides only those home care services that are deemed necessary because of an acute illness. Patients who are hospitalized for pneumonia or a stroke or a heart attack can have personal care services at home (a homemaker or health aide) while recovering from their acute medical problem as long as they are also receiving some type of skilled care at home such as a visiting nurse or a physical therapist. Medicaid is more generous in its coverage of home-based personal care services by not tying them exclusively to a single episode of illness, perhaps recognizing that it is cheaper to pay for a personal care attendant at home on a long-term basis than to pay for the alternative, which is residential nursing home care. Nonetheless, the number of hours of personal care available per person per week is very limited: two hours a day, several times per week, is a typical benefit; four hours a day, seven days a week is a rare extensive benefit. 

            Lastly is medical care. Because Medicare was initially crafted as an acute medical benefit, intended to address short-term medical care, it provides good coverage for hospitalization and brief post-hospital care in a skilled nursing facility or similar site. It also has comprehensive out-patient coverage, but it was never intended to promote medical care at home—even when “home” is a nursing home.  Long-term care, by definition, is chronic. Only recently has Medicare added a chronic disease management benefit in recognition of the reality that fully 68 percent of Medicare beneficiaries have at least two chronic conditions—and another 37 percent have four or more chronic conditions. More recently still, the CMS Innovation Center (authorized by the Affordable Care Act) launched the “Independence at Home” demonstration project, which provides for home-based primary care, but this initiative is capped at 10,000 enrollees. 

            What are the consequences of a system that sees itself as providing a medical rather than a long-term care benefit? Because coverage of supportive services is modest—whether for home health aides or homemakers or transportation—the system tends to favor institutional care over home care. Services that might enable frail older people to continue to live at home are insufficient, driving them into nursing homes; services that would facilitate treatment of acute medical problems at home are lacking, promoting the use of hospitals. For nursing homes, there are additional consequences. Nursing home regulations, promulgated by CMS but monitored by local health departments, focus on safety and adherence to selected public health measures, such as annual flu shots, rather than on quality of life. Paradoxically, physicians are paid separately by Medicare and are not included in per capita Medicaid payments, a system that promotes highly individualized medical care rather than a focus on the community.

            The failure to recognize the importance of long-term is unique to the United States in the developed world. European countries provide a comprehensive long-term care benefit for older and disabled individuals. The structure of the benefit and the mix of private and public services available using the benefit are highly variable from country to country. 

            Most European countries offer universal coverage, with nursing and personal care available to all eligible individuals (based on an assessment of their level of dependency in basic daily activities). Co-payments and deductibles are common, typically subject to income thresholds. In a number of countries, frail older people can choose whether to receive that personal care in their own home, in the home of a family member, or in an institutional environment. In some models, they can opt to receive a cash benefit rather than an in-kind benefit, and can use the cash to maintain their independence, whether by remodeling their home to make it more accessible or to pay for private aides.

            In Denmark, for example, priority is given to community over residential care. A frail older person living in his own home or in a special dwelling for the elderly is entitled to home health services (generally nursing and rehabilitative care) and practical help (assistance with shopping, cleaning, meal preparation and personal care). Both health care and long-term care are public responsibilities. LTC financing and provision are the responsibilities of the local municipality and health services are planned and operated on a regional level. A case management system serves to coordinate the health and long-term care components of care. The system is financed through both local and national taxation.

            The existence of a long-term care benefit would not, by itself, have prevented COVID-19 from sweeping through American nursing homes. But it would likely have decreased the number of frail older people who live in nursing homes and assisted living facilities in the first place. For those individuals who nonetheless required an institutional environment, a long-term care orientation would have meant attention to quality of life, which would have resulted in private rooms and single bathrooms. This sort of living arrangement is far more conducive to limiting the spread of an infection than are the old-fashioned double or even four-bed rooms. 

            Once we reconceptualize nursing homes as primarily places where people live and only secondarily as sites for the delivery of health care services, we can move on to our next challenge: designing a branch of medicine that addresses both the individual geriatric needs of residents (advance care planning, incontinence treatment, fall prevention, avoidance of polypharmacy, etc.) and community health needs (flu shots, sanitation, good nutrition, etc). If we minimize the number of frail elders requiring institutional care by supplying community services, and we then modify the nature of the medical care provided within those institutions, we can anticipate a lesser toll from the next epidemic—and an improved quality of life for society’s frailest and oldest members.

August 28, 2020

After the Deluge

Nursing homes are at a crossroads. Unpopular before the pandemic, Covid-19 has brought them to a new low. There was the epidemic itself, which swept through nursing homes and assisted living facilities, causing an estimated 40 percent of all thevirus-related deaths in the U.S. Then there was the response to the epidemic: the draconian measures taken to control the outbreak caused social isolation, depression, and sometimes confusion in residents.  Next were the institutional consequences: the deaths that inevitably result when vulnerable people became ill (with a mean age of about 85 and multiple underlying health conditions, nursing home residents are at the highest risk of contracting and then dying from Covid-19) led to empty beds but the quarantine made it difficult to fill them. Empty beds meant less revenue, this at a time when costs were rising due to the need for frequent deep cleaning, personal protective equipment, and supplementary staff. 

The future looks grim as nursing homes face a loss of confidence in their ability to provide good care and as state budgets, which determine the level of nursing home reimbursement through Medicaid (the homes' major source of revenue), are strained by the recession. What, then, will become of nursing homes after the deluge? 

In a provocative essay, Charles Sabatino of the American Bar Association argues that “it’s time to defund nursing homes.” Institutional care as defined by the average American nursing home, he suggests, is simply not what old people or their families want. It’s demeaning, disrespectful, and disgraceful. Moreover, to those who claim the institutional environment is necessary to keep the oldest, frailest members of society safe, the monumental failure of nursing homes to prevent sickness and death during the COVID-19 pandemic provides ample evidence that even in this arena, the nursing home is a failure. Medicare and Medicaid, which together fund a large proportion of skilled nursing home care (Medicare pays for short term rehabilitative care while Medicaid pays for long-term residential care) hold the key. They should pay for care only, Sabatino says, if the nursing homes are small and homey, provide all their residents with private rooms and bathrooms, and embody a culture focused on the goals, interests, and preferences of their residents—not the nurses, nursing assistants, administrators, and others who run the institution. 

Geriatrician, palliative care specialist, and health care policy expert Joanne Lynn distinguishes among the various populations found in nursing homes and suggests different strategies for each group. People recently discharged from a hospital who need short-term rehabilitation or further medical care that they cannot receive at home—the “post-acute” patients who stay in skilled nursing facilities for a few days or at most a few weeks and whose care is paid for by Medicare—can continue to receive this type of treatment in a hospital-lite environment. People with severe brain damage, whether from dementia, stroke, or prolonged lack of oxygen, and who are unaware of their surroundings and do not recognize their family members can likewise remain in a hospital-style institution. People who are dying and who need more assistance than can be provided through home-hospice should not have to go to a skilled nursing facility under the guise that they need rehabilitation in order to have 24-hour, residential care. Instead, they should be eligible for inpatient hospice. That leaves the large fraction of the current nursing home population who are dependent on others for many of their basic daily needs—bathing, dressing, walking—due to multiple physical problems and/or moderate dementia. For those individuals, Lynn argues, the best environment is a model very much like what Sabatino advocates. This type of facility already exists: it is called the Green House Project. What is the Green House Project and how did homes built along this model fare during the pandemic? 

Green Houses are the brain child of Bill Thomas, a pioneering geriatrician who has been designing progressively better nursing homes since he introduced the Eden Alternative—bringing pets and plants into nursing homes—in the early 1990s. He then went on to mastermind what would become the culture change movement, or bringing resident-centered care to nursing homes. The model was fleshed out by the consortium of nursing homes that banded together to form the Pioneer Network, which advocated breaking large, hospital-style nursing homes into multiple discrete households, eliminating the centrally-located nurses’ station to promote integrating nursing care into daily life, and decreasing the differentiation of labor which compartmentalized care. But while many facilities endorse culture change, few have implemented its principles on a wide scale. Enter the Green House. Green Houses are built along the lines envisaged by the culture change movement—they make use of “universal workers” rather than siloing staff members into discrete categories and they are built around honoring the preferences of residents. But the critical difference is that they are small. Instead of breaking a large institution into multiple households, the Green House is a single, freestanding household with 10-12 residents. Its guiding principle is that to be homey, it needs to be built like a home and function like a home. 
The first such home was built in Tupelo, Mississippi in 2003. 

Today, there are 300 Green House sites across the country. The big question is whether these facilities in fact improved the quality of life for their residents. Have they been able to meet the health and safety requirements imposed upon conventional nursing homes? Have their costs been higher than those of standard nursing homes? And how did they fare during the Covid-19 pandemic? The most comprehensive attempt to answer the questions about quality of life and health and safety requirements is from the THRIVE Research Collaborative (The Research Initiative Valuing Eldercare), published in 2016. While the model was seldom fully implemented, the version that was utilized did not lead to a decline in the “quality indicators” established by the Centers for Medicare and Medicaid to evaluate nursing home care; it did lead to lower rates of hospitalization and greater use of hospice care than conventional facilities. Staff turnover, normally alarmingly high, was lower in Green House facilities. 

Measures of resident and family satisfaction have been harder to come by as studies tend to be very small and qualitative in nature, but enthusiastic articles have appeared in the popular press—and I cannot remember encountering any similar level of excitement, however anecdotal, about standard nursing homes. Based on the limited data available, I have been guardedly optimistic. But the Covid-19 experience has tipped the scale for me: with 95 percent of nursing homes and 92 percent of assisted living facilities reporting no cases, the Green Houses have been remarkably successful. 

Here is what we know—256 out of the existing 298 facilities supplied data for the period March-May, 2020. In the 229 nursing homes, which served 2384 elders, there were 32 positive cases among residents and only one death. In the 24 assisted living facilities serving 224 elders, there were 15 positive cases and 3 deaths. Compare this to all nursing homes in the US, as reported by CMS: as of mid-August, there have been just under 50,000 deaths in 1.5 million residents, with slightly below 200,000 confirmed cases and another 120,000 suspected cases. I



In summary, Green House nursing home residents were far less likely than their conventional nursing home counterparts to contract Covid-19, and if they did get sick, they were far less likely to die. Small really is better. 

My suspicion is that after the deluge, when the pandemic finally fizzles, legislators and healthy policy mavens will look to new regulations to try to prevent or at least diminish the ferocity of future outbreaks. Requiring nursing homes to have infectious disease consultants—a rule that was instituted by the Obama administration and undone by Trump—makes sense. Demanding regular testing for nursing assistants if there is another viral epidemic with similar characteristics makes sense—as was recently mandated by CMS for nursing homes during Covid-19. Systematically engaging residents and families in discussions of their preferences regarding end of life care before they are faced with a crisis is good generally a good policy, because nursing home residents are always at high risk of death, not just during a pandemic. 

But more effective change will not come from regulations. It will require a wholesale rethinking of institutional long-term care. The Green House project is a good place to start.

July 30, 2020

Have We Been Barking Up the Wrong Tree?

More of my blog posts deal with dementia than with any other subject and the news about Alzheimer’s disease over the years has been largely dispiriting, so who would have thought that I would leap at the opportunity to write about a new diagnostic test. But with so much of the medical literature relentlessly focused on COVID-19, it’s reassuring to realize that research on other subjects is continuing. The new study does not report a treatment, let alone a cure for Alzheimer’s disease. Furthermore, the prospect of screening healthy individuals to determine their future risk of developing progressive cognitive impairment is ethically fraught. Nonetheless, in the current climate, this report is good news.

It’s good news, and not just because it indicates that not all medical scientists have retooled as corona virus researchers, though it does that. It’s good news, and not just because it means it will be possible to target intervention studies to high risk individuals will permit studies to be carried out on smaller numbers of people and over a shorter period of time, though it means that. It’s good news because it shines a bright light on a long-neglected character in the Alzheimer’s story, the tau protein. 

Back in 1906, when Alois Alzheimer peered into his microscope at tissue from the brain of a patient who had died of the disorder of cognition that would one day bear his name, he identified two unusual substances that he described as plaques and tangles. The plaques, which were located between neurons, would ultimately be found to be composed of a protein known as amyloid. The neurofibrillary tangles, which were located inside the nerve cell bodies, would eventually be identified as a protein called tau. These two substances have been recognized as the hallmarks of Alzheimer’s disease for over a century.

For years, the roles of amyloid and tau were hotly debated. Some researchers felt that amyloid was the result of Alzheimer’s; others were confident it was the cause. Some scientists were more interested in studying amyloid; others directed their efforts towards tau. But over the course of the last 25 years, amyloid has gained the upper hand. Study after study has sought to improve cognition in Alzheimer’s disease by ridding the brain of amyloid-laden plaques—and each time, the approach failed. 

A great deal of excitement was engendered by immunotherapy back in 2001: the idea was to stimulate the body to create antibodies against amyloid with what was essentially a vaccine—but the study had to be stopped because a subset of patients developed meningitis. Then there was enthusiasm about the use of monoclonal antibodies. Several such antibodies have made it to phase 3 trials in which their efficacy was compared to placebo. In 2014, two studies of Bapineuzumab showed no benefit. In 2018, Solznezumab was tried for individuals with mild Alzheimer’s and it was unsuccessful. In the same year, additional negative results were reported for Verubecestat in people with mild to moderate Alzheimer’s. 

All these negative studies don’t exonerate amyloid. Maybe the trials are initiated too late in the course of these disease’s development. Maybe the dose is too low. But with anti-amyloid strategies repeatedly striking out, I can’t help but wonder, as have others who know much more about the science than I do, that we’re looking at the wrong target.

Which is why the new study that focuses on tau is exciting. The authors found that their tau antibody test was able to diagnose Alzheimer’s disease as well as or better than more invasive existing tests—when they used the test in patients all of whom had some kind of neurodegenerative disease. That is, the test did well in answering the question: is this person being tested more likely to have Alzheimer’s or, say, Parkinson’s? That’s a very different question from: is this person normal or does he have Alzheimer’s? Not only was the population in which the test was studied composed exclusively of patients with some neurologic condition, not only did the population include a much larger proportion of people with Alzheimer’s than would be found in the general population, but the subjects were far from ethnically or racially diverse. So, it’s a long way from the article in JAMA to a widely useful diagnostic test.

Despite the test’s preliminary nature, it is a compelling piece of evidence that tau should get more attention. Two weeks before the on-line publication of the JAMA study, a small Swiss pharmaceutical company, AC Immune, announced that together with Johnson & Johnson, it was launching a trial of a vaccine designed to stimulate the body to produce antibodies against tau—leading its stock price to soar by 18.9 percent. Just a few weeks earlier, the giant Swiss pharmaceutical company, Roche, announced it, too, was investing in the development of an anti-tau vaccine. 

It’s too early to say whether the attack on tau will fizzle, much like the previous attacks on amyloid. But maybe, just maybe, it will be a rousing success.







July 17, 2020

What's the Risk?

Nearly six months into the pandemic, we ought to know the important risk factors for serious illness or death from Covid-19. Whether because of poor record-keeping, lack of international cooperation, or sloppy statistical analysis, the information until now has been limited. 

Not just limited; the claims about risk factors to date have been quite misleading. I complained in my blog post in early May that the rates of certain conditions in patients dying of Covid-19 were actually no different from the rates of those same conditions in older people in general. For example, I noted that one study reported that the rate of high blood pressure in patients with severe cases of Covid-19 was 56.6 percent—but failed to comment that the rate of high blood pressure in the elderly population is 60 percent. Far from indicating that high blood pressure increases the likelihood of severe Covid-19 in older adults, this finding suggests that high blood pressure confers no extra risk or maybe is even protective. 

The only consistently observed risk factor for both severe illness and death has been older age, with age greater than 80 representing very high risk. Now, thanks to the existence of widespread, compatible electronic medical records in the British National Health Service (NHS), we have some useful data.

The study, published early on line in Nature Reviews, compares British patients who died of Covid-19 with all other British patients who are cared for in a group practice that used the necessary software (approximately one-third of the population). By using “a secure analytics platform inside the data centre of major electronic health records vendors, running across the full live linked pseudonymised electronic health records,” and after excluding people under age 18 and those with less than a year's worth of data, the investigators were able to collect health information on over 17 million individuals, including just under 11,000 with Covid-19 related deaths. The results confirm age as the single most potent risk factor, with a small number of other major risks.

To capture the most striking findings, I extracted data from the chart listing the hazard ratios (HRs) and 95% confidence intervals (CI) for Covid-19 death (Table 2) and present 3 separate tables: one highlighting very high-risk characteristics, one highlighting high-risk characteristics, and one showing characteristics associated with no or minimally increased risk. For added emphasis, I highlighted hazard ratios of greater than 3 in red and hazard ratios between 2 and 3 in blue.

Characteristics Associated with Covid-19 Deaths


The important difference between these charts and previous attempts at quantifying risk is that the hazard ratios reported have been age and sex-adjusted and have been further adjusted for other potential confounders along with age and sex.  

The conclusion from this analysis is that when we consider the age- and sex-adjusted hazard ratios, there are only four very high-risk conditions: old age, a hematologic malignancy diagnosed within the previous year, severe kidney impairment, and organ transplantation. Within the old age categorization, the hazard ratio goes from 8.62 to 38.29 as the age increases from 70-79 to 80 and older (the reference group is people aged 50-60). The only medical condition that comes close to this magnitude is organ transplantation, with a hazard ratio of 6. 

Another handful of conditions are in what I have classified as high-risk: obesity with a BMI of 40 or greater, poorly controlled diabetes, stroke or dementia, a hematologic malignancy diagnosed between 1 and 5 years earlier, liver disease, and other forms of immunosuppression. Incidentally, four out of six of these conditions drop out if we look at the “fully adjusted” column.

It’s worth noting some of the chronic conditions that were not associated with increased risk. High blood pressure, as I had previously suggested by comparing the rate in the very ill Covid-19 patients with the rate in the general older population, does not appear to be a risk factor. Mild to moderate asthma, defined in this study as someone with asthma who did not use oral steroids within the previous year, is also not a risk factor.

It’s also worth noting that the CDC has issued its own guidance about risk factors for Covid-19. Their conclusions, while overlapping with the NHS data, differ in important ways. Most important, their methodology differs. The CDC, lacking a domestic large, comprehensive data base, is forced to draw on evidence from small case series, cohort studies, and some meta-analyses, as well as a much earlier preliminary report from the NHS. The new NHS data, rigorously obtained and meticulously analyzed, should be seen as the gold standard.

July 14, 2020

When Will We Ever Learn?

Residents of long-term care facilities in the US have been hit harder by the COVID-19 pandemic than have any other group. They have almost all the known risk factors for becoming seriously ill with the disease: they are unambiguously old, with fully 41 percent over age 85, and almost all have one or more chronic diseases, generally multiple conditions that result in their needing personal care. To top it all off, they live in close proximity to one another, typically eating together in a common dining room and often sharing a room with another resident. As a result, nursing home residents account for at least one-third of U.S. COVID-19 deaths. In some states, such as Massachusetts, estimates by early May were that nursing home residents accounted for 60 percent of COVID-19 deaths. 

We learned from the devastating early experience with COVID-19 how to keep the corona virus from causing havoc in nursing homes. In particular, we came to understand the importance of protecting nursing home residents from staff members who might bring it into the facility. By testing staff regularly and mandating head to toe personal protective equipment, together with other draconian measures such as banning family visitors and restricting resident-to-resident interaction, the rate of illness, hospitalization and death among nursing homes residents plummeted. Now that the virus is again surging in the Sunbelt, with Florida, Arizona, and Texas reporting skyrocketing infection rates, how are nursing home residents faring in those areas?

The answer, in a word, is not well. The Florida Department of Health reported 3072 active cases in nursing homes and assisted living facilities as of July 13, up from 1408 on June 23. The rate had nearly doubled in two weeks.  Houston saw an 800 percent increase in cumulative new cases among nursing home residents between the end of May and the end of June—and Texas has more nursing homes than any other American state. 

Why is this happening? Only in mid-July did Florida announce it would test nursing home staff regularly. The government defined regularly as every other week—not likely to be often enough—but many facilities report no testing has taken place as yet. Phoenix nursing homes report a shortage of personal protective equipment, with 25 percent of facilities acknowledging they have only one week’s worth of masks, gowns, and gloves on hand for nursing assistants and other direct care personnel. 

So far, death rates have not soared the way they did in New York during the height of its outbreak, but they are beginning to rise. As epidemiologists point out, death is a “lagging indicator:” people first get sick, then some of them become sick enough to require hospitalization; next, some are admitted to the ICU, and then, over a period of weeks, the deaths start coming. The outbreaks began with younger people who ignored public health recommendations to wear masks, limit group gatherings (especially indoors), and maintain physical distance from others. Florida, Texas, Arizona, and other hot spots did not engage in a vigorous campaign to test people with symptoms, to isolate anyone with an infection, and to quarantine exposed individuals. The result was community spread. At that point, the outcome for nursing home residents is entirely predictable. Once COVID-19 is widespread in the community, it is going to make its way into nursing homes, carried by asymptomatic or minimally symptomatic staff members who do not wear adequate protective gear. And vulnerable older people who are dependent on staff members to go to the bathroom, to eat, to dress, and to bathe will themselves become ill. More and more of them will become very sick and many will die. 

States that experienced a major outbreak early in the course of the pandemic—in late March and much of April—learned through experience that in the absence of a vaccine or effective treatment, old-fashioned public health methods are the only scientifically sound and morally defensible way to act. The invasion of nursing homes has no doubt already begun in the states with soaring case rates; every hour of delay in instituting the only measures that we have just demonstrated can succeed will result in more viral transmission, more suffering, and more death.

June 19, 2020

Telemedicine Tips



For years, Medicare has defined a visit with the doctor, what it calls an "encounter" as comprising the history, physical exam, and lab tests.  Without the face to face component, from Medicare's perspective, there can be no visit. Telemedicine has changed this perspective. For some time, Medicare has allowed telemedicine visits in rural communities and for consultation between physicians. The pandemic has forced Medicare to adopt a new standard for a visit. But just because Medicare now pays physicians for these new encounters and just because software is now available  to facilitate patient/doctor interactions in a secure way doesn't mean it's obvious how best to use the technology. Older patients, some of whom do not use the internet, are often uncomfortable with such a system. To benefit from telemedicine--and no group is more in need of being able to interact with the medical profession remotely than older individuals--they will need help from caregivers.
Here's a video for family caregivers to give them some ideas about  making optimal use of telemedicine.



May 22, 2020

Doctor, Meet Family Caregiver

Here's a short video pitched to physicians, extolling family caregivers and explaining how partnering with caregivers can help both physicians and patients.

May 05, 2020

What's the Risk?

            A new study of 5700 consecutive COVID-19 patients hospitalized in the New York area is making waves because it reports a high rate of underlying chronic disease, seemingly amplifying findings from Wuhan and elsewhere. But what is striking about this group of severely ill COVID-19 patients is not so much their associated chronic conditions as how similar they are to much of the general population.  
            The study, published in JAMA, reported obesity in 47.7 percent of patients, very much like the rate among adults generally: 44.8 percent of 40-59-year-olds and 42.8 percent of those over age 60 are obese. For high blood pressure and diabetes, the rates of disease in the COVID-19 patients closely resembled the rates in the older population in general. The study found high blood pressure in 56.6 percent of the COVID-19 patients; that’s awfully close to the rate of 60 percent found in the general population among people over age 65—and considerably higher than the rate of 33.2 percent found in the general population among people aged 40-59. And the study noted that diabetes was present in 33.8 percent of the very ill COVID-19 patients; that is fairly similar to the rate of 27 percent found among the elderly in general—and markedly higher than the 17.5 percent typically found in the general population of 45-64-year-olds.
            To better understand the significance of the observations about chronic conditions in the COVID-19 patients, the authors of the JAMA article need to examine age-specific rates of those disorders. Without this information, we can’t say very much about risk factors—except that obesity doesn’t seem to be much of a risk factor at all since its rate in the hospitalized COVID-19 is very similar to that in the general adult population. What about hypertension and diabetes?
            Since the median age of the patients in the JAMA study is 63, that means that about half the patients are elderly and about half are not. If all we know is that the rate of high blood pressure in the patients is 57 percent, then there are three possibilities: 1) that 57 percent figure applies across the board, regardless of age; 2) the rate among the half of the study population that’s over 65 is greater than 57 percent (in which case the rate among the half that are under 65 is less than 57 percent); or 3) the rate among the half of the study population that’s over 65 is less than 57 percent (in which case the rate among the younger patients is more than 57 percent). 
            Let’s put sample numbers on these 3 situations, comparing them to what we know about rates in younger and older people in general. In the first case, where the 57 percent applies to everyone, regardless of age, this would mean that the risk of high blood pressure in the older population is the same (or a little lower) than in older people without COVID-19, where it’s 60 percent; and much, much higher than in the younger population, where it’s 33 percent. In the second case, let’s suppose the actual rate of hypertension in the older COVID-19 patients is more like 70 percent (higher than the 60 percent in the well elderly); that would imply the actual rate in the younger COVID-19 patients must be around 44 percent (higher than the comparable rate in healthy younger patients of 33 percent). In the third case, let’s suppose that an average hypertension rate of 57 percent means the actual rate of hypertension in the older COVID-19 patients is 44 percent (much lower than among healthy elderly) and the actual rate among younger COVID-19 patients is 70 percent (much, much higher than among healthy younger adults). What’s noteworthy among these three possibilities is that only in one of them is hypertension a risk factor in the elderly (case 2); in the other scenarios it's either not a risk factor or is actually protective. Moreover, if it is a risk factor, it may well confer only modestly increased risk.
            Whatever the relationship between chronic disease and the severity of COVID-19, what is clear is that Americans as a whole have high rates of chronic disease. A recent international comparison of health found that the US has a rate of chronic disease and obesity that is twice that of other developed countries. Among fee-for-service Medicare beneficiaries, the latest statistics reveal that 20 percent have between 2 and 3 chronic conditions; another 23 percent have 4-5 chronic conditions, and fully 17 percent have 6 or more chronic diseases. 
            Before we make older people with diabetes or high blood pressure unnecessarily anxious about contracting COVID-19—or falsely reassure those older people who don’t have diabetes or high blood pressure that they are at low risk—we need a more careful analysis. Perhaps the real take-away message from the JAMA study is that the U.S. needs to do a better job preventing chronic disease.

April 29, 2020

What Has Become of the Patients?

Frontline physicians are reporting a mysterious phenomenon—as hospitals began preparing for and in some cases started receiving an onslaught of COVID-19 patients, patients with other conditions such as heart attacks, stroke, and appendicitis became a rarity. Where, asks the New York Times, are all the patients?

While much of the evidence about declining hospitalization rates is anecdotal, hard data are emerging.The information from disparate sources now strongly suggests that the decline in hospitalization for heart attacks, strokes, and other potentially treatable serious medical problems is real. 

Assuming that the rate at which Americans develop these problems has remained unchanged, and there’s no reason to believe otherwise, the logical conclusion is that patients are staying home. Given this likelihood, the important question to ask is not where are the patients. It’s what’s happening to them? Are they dying? Are they surviving but with significant, avoidable deficits? Or are they doing just fine? And why did they stay home? Were they terrified of going to the hospital, worried about contracting COVID-19, and did not even call their doctor for advice, as is generally assumed? Or did they try, unsuccessfully, to contact a physician by phone or video? Might they have succeeded in reaching a physician but were given poor advice?

We urgently need to investigate the fate of these patients who are performing an uncontrolled natural experiment in home vs hospital care. Physicians tend to assume that the problem is that patients are self-diagnosing and self-treating—to their detriment. But we may find some surprises, both in terms of why patients are staying home and what is happening to them. We might discover that some patients tried to obtain advice and for a variety of reasons were not directed to the emergency department. And we may learn that the outcomes varied, with some patients dying, others surviving but suffering needlessly, and still others doing just fine. While drawing robust conclusions will be challenging because of a lack of a randomized control population, interviews may enable to learn something about the factors that shaped patient behavior and contributed to outcomes.

Telemedicine has to a large extent replaced person to person visits during the COVID-19 epidemic. As a result, when we blame patients for their failure to go to the hospital, we are implicitly assuming that the flaw is in the patients and not in telemedicine. But such a conclusion is too facile. Maybe part of the responsibility lies with the limitations of telemedicine. Maybe telemedicine is an art that physicians need to master, and maybe patients need to be educated about how best to make use of telemedicine.

Consider this analogy: physicians used to believe that anyone trained to take care of patients in the hospital setting automatically knew how to care for them in the office. Only relatively recently did educators suggest that outpatient medicine requires different knowledge and skills from inpatient medicine. As a result, residency programs today have a much larger and more robust outpatient component than did their predecessors 30 years ago. The recognition that patient engagement in their own medical care positively affects outcomes likewise led to a change in the way that primary care physicians are supposed to practice medicine. 

Teaching both physicians and patients how best to utilize telemedicine will also require that learning more about the barriers to the use of telemedicine in the primary care setting—are people who do not have a computer or smartphone simply not contacting their physician? Do older people who have been unable to learn to make a video call assume that telemedicine is unavailable to them? What about on the physician side? Are all primary care physicians using Zoom or its analogs?

Once we have identified and rectified the barriers to use (no mean feat), we will need to figure out how to optimize use of this technology. Patients may have to be equipped with the means to measure their own blood pressure, temperature, and oxygen saturation to be able to provide physicians with crucial data. Physicians may have to learn to ask patients to check for peripheral edema or other signs of illness, and they may need to rely on third parties (home health aides or family caregivers) to provide additional information.

At the same time, we need to clarify whether sick people are currently underutilizing hospitals (the widespread assumption) or whether they were previously over-using hospitals. While there is ample evidence that hospitals have a great deal to offer patients with conditions such as heart attacks and appendicitis, there is also extensive data suggesting that many medical treatments are over- prescribed.

Over the short run, we need to get out the word that hospitals are open for business and have the capacity and the ability to care for patients with all kinds of acute problems, not just COVID-19 pneumonia. But over the long run, we need to learn how and when to best use both telemedicine and hospital care.


April 27, 2020

The Doctor is On Line

The Commonwealth Fund just released a study reporting on primary care office visits in the COVID-19 era and it’s disturbing. In-person office visits fell by 60 percent in March and remained down to nearly the same extent in April. While telemedicine substituted for some of these visits, it did not come anywhere near to compensating for the decline. 

Clearly the precipitous fall is disastrous for primary care medicine, which has seen one practice after another furlough physicians or close altogether, but it also bodes ill for patients. While some of those vanishing visits were probably unnecessary or could easily be postponed, there is reasonably good evidence for the efficacy of robust primary care medicine in improving health and increasing longevity. What can we do about this problem—apart from eradicating COVID-19?
            
The popular answer is to increase the use of telemedicine. Telemedicine—principally video calls by patients to physicians that allow both parties to remain home—have had considerable successes: Jefferson Health has made extensive use of the technology to screen for COVID-19, to enhance prevention and, to some extent, to treat common conditions. The use of telemedicine has been rising dramatically, with some analysts reporting a 50 percent increase since March and others predicting a billion remote visits by the end of 2020. Moreover, the regulatory changes introduced by Medicare to facilitate billing for telemedicine visits have had a major beneficial impact. 

But before we get carried away, we should consider who is not currently using the technology and what adaptations will be necessary to maximize its efficacy. I worry that older people in general and the oldest old in particular are not availing themselves of telemedicine, despite having the greatest need. Older patients who are poor, have little education, or are non-English speakers are at the greatest disadvantage of all. But to assume that the only barrier to effective utilization is lack of access strikes me as naïve: surely new skills and a new approach will be necessary, both on the part of physicians and of patients.

First, the barriers to access. My mother is 94. She is intelligent, she has a master’s degree in social work, and she owns a computer and a tablet, both of which she uses to read her email. But video calling is just beyond her. I’ve tried FaceTime and Zoom. I sat with her (in the days when I was able to do so) and coached her. I’ve attempted to walk her through the process while we are on the phone together. No luck. And she is not unique. Her friends have not been able to master this skill either. Generations on Line, an organization which for decades has been trying to improve digital literacy in the elderly, identifies three obstacles: lack of access (not an issue with my mother or most of her friends), lack of skill, and intimidation. She is convinced she cannot learn to use this technology. “I’m not made for this century,” she tells me and she is not alone in her conviction.

Now consider all the older people who do not have a computer or a tablet. Internet use has been steadily rising in those over age 65 and is now about 73 percent—but among those age 80 or older, it’s only 44 percent. And use falls further with lower income and lower levels of education. 

Then think about those who are hearing impaired—you might imagine that the computer's capacity for amplification would be a benefit of the technology, but for many people with hearing loss, the main problem is discrimination, the ability to distinguish different sounds, and that does not disappear with amplification. Next, throw in non-English speakers. Good systems are available for dial-in interpreters, which works well in the office setting, when the patient and the physician are in physical proximity, but is more challenging when a three-way video call is required. Until these barriers are overcome, telemedicine will be limited to telephone calls in those who are neediest and most vulnerable. 

Even if we could wave a magic wand and all older people would have a computer, smartphone, or tablet and broadband access and the ability to use the device to communicate with their physician, we would still need to address the issue of reaching the doctor in a timely fashion. If telemedicine is supposed to replace urgent care as well as evaluation of new, slightly less acute problems along with chronic disease management, then we will need a systematic way to triage visits. 

If all older people could communicate with the physician via the internet promptly and effectively, there would remain the question of the substance of that interaction. Medical students are taught that a good clinical history results in (presumably correct) diagnosis 80 percent of the time. But a more sophisticated analysis suggests that how likely the history is to prove adequate depends on the prior probability of the condition—that is, if a patient is extremely likely to have pneumonia, then a physical examination or chest x-ray has relatively little to add to the history, but if the chance of pneumonia is small, then these other modalities can add significantly. For telemedicine to be effective, we will need to compensate for the lack of a physical exam and lab tests.

Video adds an important dimension to the visit—physicians can learn a great deal, for example, from observing if the patient is struggling to breathe or has blue-tinged lips. But even in dermatology, physicians rely on touch as well as vision to evaluate a rash. To maximize the effectiveness of telemedicine, patients will need to be able to provide their physicians with critical data. They will have to have a thermometer at home to report their temperature. They should have an electronic home sphygmomanometer to measure blood pressure and, ideally, a pulse oximeter to measure the amount of oxygen in their blood. They should know how to check their pulse (though typically home blood pressure cuffs will do this) and respiratory rate. Obtaining the necessary equipment and learning to use it should be feasible, but it will take time and effort.

Lastly, physicians will need to tailor their approach to a visit to accommodate the strengths and weaknesses of the technological medium on which it is based. A video visit is not identical to an office visit, which in turn is not the same as hospital care. Just as physicians discovered that they could not simply extrapolate from inpatient medicine to the outpatient setting but rather had to learn different strategies for caring for ambulatory patients, similarly they will need to adapt to the brave new world of telemedicine. 

Over the long run, the adaptation will be worthwhile. Better home care can lead to fewer hospitalizations. Fewer hospitalizations means better outcomes for frail older patients: they were at risk of adverse consequences of hospitalization (falls, confusion, decline in self-care ability) long before they were at risk of COVID-19. But we have a long way to go.

April 22, 2020

If We Had 2020 Vision, What Would Nursing Homes Look Like?

Futurism is all the rage: worn down by the relentless drumbeat of Coronavirus hospitalizations and deaths, the mind-numbing unemployment statistics, and the unimaginable reality of parents trying to work while home-schooling their children, we are beginning to think about life-after-the-epidemic. Will movie theaters survive? Restaurants? What about orchestras and theater companies? Will doctors and researchers fly across the country and even across the ocean to attend conferences? Will anyone ever go on a cruise again? The answers to these questions have implications for how we will live our lives, for the environment, for the economy…the list goes on and on. But today’s NY Times speculates about another possible casualty of the COVID-19 outbreak, nursing homes. Battered by an acute rise in costs together with a precipitous decline in revenue as admissions fall, and shattered by their new reputation as a “petri dish for the worst pandemic in generations,” America’s nursing homes risk going under.

The US currently has roughly 15,400 nursing facilities which house 1.5 million of the oldest, frailest, most vulnerable people in the country. The Centers for Medicare and Medicaid (CMS) calls these facilities skilled nursing facilities; most of the rest of us refer to them as nursing homes. To confuse matters, the majority of these skilled nursing facilities (referred to as SNFs and pronounced “sniffs”) also provide care to another 1.5 million Medicare beneficiaries who are admitted for a short period, typically a few weeks, following an acute hospital stay. They are transferred from the acute hospital for rehabilitation or to complete a course of medical treatment prior to returning home. 

Skilled nursing facilities are paid by Medicare for short-term “post-acute care;” they are paid by Medicaid or privately, by the residents themselves, for long-term residential care. And while the subacute part of the business is profitable—according to the MedPAC (Medicare Payment Advisory Commission) “Report to Congress” just published last month, profit margins are 18 percent—the long-term residential component is not. Profit margins in the residential component are non-existent, with the latest, 2018 figures averaging negative 3 percent. Residential, long-term care SNFS were financially precarious before the COVID-19 epidemic. So, it is not surprising that they are faring especially poorly during the epidemic.
             
While the major toll, as the NY Times has reported, is the 7000 deaths among a total of 36,500 nursing home residents diagnosed with COVID-19, there has been a huge financial hit as well. One non-profit chain in Minnesota reported that the average 72-bed nursing home has been spending an extra $1922 per day on personal protective equipment for staff members and another $1500 per day for extra staff to care for residents who are in isolation or who are substituting for staff who are out sick. At the same time, revenue is down because facilities cannot fill their empty beds. Nursing homes have large fixed costs to cover salaries for staff, mortgage payments, food, and equipment. What they don’t have is much reserve. 

In light of these statistics, what will nursing homes do? What will happen to the 1.5 million Americans, who live in these facilities today? One way to imagine the future is by looking at the past. And it turns out that once before, in the not too distant past, the nursing home industry experienced a great contraction.

A funny thing happened in the late 1970s and early 1980s. Despite decades of growth of the elderly population and dire predictions about imminent shortages of nursing home beds, the demand for nursing homes fell. It fell because the baby boomers read books like “Tender Loving Greed” by Mary Adelaide (1974) and “Why Survive? Growing Old in America” by Robert Butler (1975) and concluded they didn’t ever want to go into a nursing home. Not only that, but they didn’t want to see their parents enter a nursing home. In response to the growing demand to stay at home and “age in place,” Medicare expanded its home health benefits: federal legislation in 1980 (the Omnibus Budget Reconciliation Act, known as OBRA 1980) relaxed prevailing restrictions on the ability of Medicare patients to receive nursing, physical therapy, occupational therapy, and other services in their homes. 

Then, in the mid-1980s, a new kid arrived on the block. Touted as promoting dignity and fostering independence, the new institution, which came to be called assisted living, was supposed to keep older people out of nursing homes by offering them the help they needed in the privacy of their own apartment. Between 1991 and 1999, the number of such facilities increased by 49 percent. Between 1998 and 2003, the number increased another 48 percent. Fortune Magazine reported that assisted living was a leading growth industry and that Wall Street investors were falling all over each other to get a piece of the action.

As assisted living and home care grew in popularity, the demand for nursing home care fell, relative to the population. That is, the absolute number of nursing home beds continued to increase, reflecting the growth of the older population in general and of the population over 80 in particular. But by 1980, the number of nursing home beds per person over 65 had begun to fall. A study published in 1985 projected the elderly nursing home population would rise from 1.2 million in 1980 to 1.9 million in 1995 and to 2.8 million in 2020. But here it is 2020 and the number of older people in nursing homes is back down to 1.2 million—the same level as 35 years ago.

Did nursing homes close in response to the fall in demand in the 1980s and 1990s? Some did. But many simply retooled. At just about the same time that assisted living began replacing nursing home care for many older individuals, Medicare made a dramatic change in the way hospital care was paid for, a change that would have an equally dramatic impact on nursing homes. What happened is that Congress passed legislation requiring that Medicare bill for hospital care using prospective payment. Accordingly, Medicare introduced the concept of “diagnosis related groups” in 1983, essentially paying a flat fee to hospitals for a given medical problem, say a heart attack or a broken hip, rather than reimbursing hospitals on a per diem basis. 

The implications of this payment model were immediately apparent to hospitals: since the rates assumed an average length of stay for a given diagnosis, any hospital that discharged patients sooner than the average made a profit and any hospital that discharged patients later than average sustained a loss. The incentive to discharge patients “quicker and sicker” was clear. How to do this with older patients, many of whom were weak and debilitated after their acute problem had been addressed, was less clear. 

Enter the skilled nursing facility, aka the nursing home. A little used proviso in the original 1965 Medicare legislation provided for “post-hospital extended care” in a “qualified facility having an arrangement with a hospital for the timely transfer of patients.” When acute care hospitals looked around for a place to which they could send patients (usually older patients) who were well enough to leave the hospital but not well enough to go home, they seized on this clause. Suddenly they saw nursing homes in a new light. Here were medical facilities that provided round the clock nursing care, room and board, and were accustomed to caring for older people. And those nursing homes had empty beds. 

Not only did nursing homes have empty beds but, as they soon learned, they would be reimbursed much more generously by Medicare if they used the beds for “rehabilitative” or “post-acute care” than they would be by Medicaid if they used them for long term care. On average, Medicare today pays $503 per patient per day for SNF care whereas, on average, Medicaid pays $206 per person per day for residential care.  As a result, use of the short-term skilled nursing benefit soared, going from minimal utilization in the 1980s to 2.2 million admissions in 2018, at a cost to Medicare of $28.5 billion. Not surprisingly, almost all skilled nursing facilities now accept short-term patients. A few take short-term patients only. 

So, what can this slice of history teach us about the predicament of nursing homes today? First, odds are that some nursing homes will close. Many of those that close will already have been operating at less than 100 percent capacity before the COVID-19 epidemic. Some will be temporarily bailed out by the large corporations of which they are a part, health care conglomerates that have other revenue streams. But the for-profit owners—and 70 percent of nursing homes are for-profit—will not want to borrow from Peter to pay Paul very long. They will seek to unload the failing parts of their empire as soon as possible. 

Other nursing homes will probably remake themselves. Just as their predecessors moved into the post-acute business from the strictly residential, long-term care business, today’s nursing homes may decide that the money is in the health care sector and not the residential sector. They might build on their “subacute” units—the parts of the skilled nursing facility that provide short-term care are typically physically separate from the remainder of the institution, expanding them and developing new capabilities. It would be a short leap to becoming a low-tech hospital, equipped to care for simple problems that are nonetheless too complex for patients to manage at home, such as relatively mild cases of pneumonia or kidney infections. Just as community hospitals provide some but not all of the services offered by large, tertiary care hospitals and transfer patients from one site to another if additional technologies are required, so too could skilled nursing facilities provide some but not all of the services offered by community hospitals. These new health care entities could be branded “infirmaries” or perhaps even “geriatric hospitals.” 

Acute care hospitals will in all likelihood be happy to see frail, elderly patients admitted to such facilities. They were desperate for an alternative site of care during the COVID-19 outbreak, either to house COVID-19 patients who did not require an ICU or to house hospitalized patients who had problems other than COVID-19. In the pre-COVID-19 era, they lost money on such patients because they often developed complications—falls, adverse drug reactions, acute confusion—that prolonged their hospital stay. 

What about the patients themselves? Where will they go if their nursing home goes bankrupt? After the dismal performance of the country’s nursing homes during the COVID-19 outbreak, some of which was preventable and some of which may well not have been, nursing home residents and their families will be very interested in moving to a different site of care. This will be challenging since today’s nursing home population is tremendously needy.

According to the most recent data, 41 percent of nursing home residents are dependent in four very basic daily activities such as bathing, dressing, or feeding themselves. Another 22 percent are dependent in five or more basic daily activities. In addition, cognitive impairment is widespread in nursing homes, with 24 percent of residents diagnosed with moderate cognitive impairment and 37 percent with severe cognitive impairment—where “severe” means profound limitations in communication and mobility and total dependence on others for personal care. Nonetheless, some nursing home residents will move to assisted living complexes. These facilities, which over time have come to serve an increasingly impaired population, will need to adapt to a still needier clientele. 

Other nursing home residents will move to the surviving conventional nursing homes, where they and their relatives will apply pressure to develop models of care that are fiscally sustainable and, at the same time, focus on supporting those capabilities that remain as well as compensating for those that have been lost. 

Change is often difficult and transitional periods are often marred by missteps. But if we learn from past mistakes and if we focus on what’s best for the oldest and the frailest among us, the almost inevitable shake up in the nursing home industry just may prove to be a good thing.