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.

Falling Down on the Job

We’ve heard about older people who don't go out because they're afraid they will fall. A new article in Kaiser Health News reminds us that hospitals, too, fear that patients will fall--and goes on to say that hospitals respond by keeping patients in bed, which causes its own harms. This is an important issue: as the author is at pains to tell us, 30 percent of patients aged 70 and older have more trouble carrying out the most basic tasks necessary to get by (things like getting to the bathroom or eating or dressing) when they leave the hospital than they did when they were admitted. 

Some of that deterioration is directly attributable to their acute illness, but some of it stems from the way that doctors and nurses in hospitals treat people with acute illness: they put them to bed. And if they worry their patients might fall on the way from the bed to the bathroom or to the nurses’ station, they do everything in their power to prevent them from getting out of bed. They put signs on the door saying “fall risk;” they write orders indicating the patient is not to get up without assistance; in some cases, they apply physical restraints. 

Some of the interventions meant to decrease falls don’t actually work: one particularly notorious example is side rails, which until relatively recently were widely believed to prevent falls but in fact increase the chances that if a patient does manage to get out of bed he will hurt himself. Bed alarms are another strategy that studies have now shown don’t work. But even those strategies that do decrease falls come with a steep price tag if they work by keeping patients in bed: they result in weakness, in problems with self-care, and sometimes result in serious other problems such as a blood clot. Melissa Bailey of Kaiser Health News is to be commended for bringing this issue to public attention. But what prompted her to write this article now, in December, 2019? 

Was a new study published, bearing on the issue? If so, Ms. Bailey did not cite it. Did the author have a friend or family member who deteriorated during a hospital stay because she was immobilized? Not as far as we know. Were the perils of bedrest recognized only recently? Actually, we’ve known about the hazards of immobility since at least 1960. Previously, a patient with a heart attack was treated with strict, prolonged bedrest—until it became clear that this approach led to life-threatening blood clots and other problems. Is the topic new for Kaiser Health News? In fact, KHN addressed this issue in 2016: Anna Gorman published an essay with the title “Elderly Patients in the Hospital Need to Keep Moving.” This article did not make the link between immobility and the effort to prevent falls, but it did focus on the need for older patients to get out of bed and walk. Have any articles made the connection between immobility and fall prevention more clear-cut? Two years ago, an opinion piece in JAMA Internal Medicine made that link very explicit, calling their article “The Tension Between Promoting Mobility and Preventing Falls in the Hospital.” These authors argued that Medicare’s campaign to decrease falls had created disincentives to hospitals to promote mobility—with foreseeable and regrettable consequences. So, what’s going on here?

The problem is that despite the longstanding recognition that patients in general and older patients in particular need to get up and move while they are in the hospital, practice has not changed dramatically. More accurately, it’s changed since the time when heart attack patients were kept at strict bedrest for three weeks or longer, but there has been some backsliding as hospitals try to combat falls, another major problem. And Medicare incentivizes hospitals to minimize their fall rates by penalizing them financially for “injurious falls” in their patients, but it doesn’t do much to encourage hospitals to prevent “functional decline” in those same patients. 

The authors of the 2017 essay recognized the seeming conflict between minimizing falls  and maximizing mobility; their conclusion was that Medicare should also incentivize hospitals to get patients moving. It’s a great example of “teaching to the test,” of hospitals focusing on what they’re being evaluated on—to the detriment of everything else. I’m not convinced that the right strategy is for Medicare to add yet another domain to its list of areas-covered-on-the-test. At the very least, the agency should consider rewarding good behavior rather than punishing bad behavior, since I fear that further declines in reimbursement will result in generally poor quality care.

What about patients and families? What can they do to tip the scales in favor of maintaining function? They can be the squeaky wheel that asks for a physical therapy consultation. Family members can volunteer to walk with their relative in the halls of the hospital. And there’s always my favorite solution—stay out of the hospital if at all possible. When the physician in the emergency department insists “you need to be admitted,” she’s probably thinking of all the advantages of inpatient care, but not the disadvantages. So, ask about home care. It’s not the answer if you need an operation or a procedure, but if it’s intravenous antibiotics you need, or blood thinning medication, it just might make a lot of sense.