The How of WHO--the Time is Now

The best part of the WHO report, “World Report on Ageing and Health,” is the stories. After reading a long litany of the weaknesses of the long term care system (or non-system) all over the world, it’s inspiring to learn of a model that actually works.  And what’s particularly noteworthy is that some of the programs instituted in the developing world have something to teach us in the US. 

The WHO report speaks somewhat scornfully about the high tech approaches to caregiving that are the talk of the town in the west—robotic caretakers and remote monitors that are likely to be too expensive for widespread use. Instead, it touts an interactive, web-based support tool for caregivers of people with dementia. It can be accessed via computer, tablet or, what is most useful in the developing world, smart phone. The educational portal offers eight lessons for caregivers, complete with homework, and provides a coach to grade the homework. 

Another surprise: Turkey has developed a system of integrated health and social care (the only truly integrated forms of senior care in the US are nursing homes and PACE, a small program providing medical and social services to older individuals who have Medicare and Medicaid and are nursing home eligible). In the Turkish system, which is free to families and is funded through taxes, municipal budgets, and premiums paid by workers and employers, the Ministry of Health provides health care at home, delivered by a multidisciplinary team. The ministry of Family and Social Policies offers social support in multiple sectors. And municipalities provide services such as home health aides and home repairs.

Creating an “age-friendly” world sounds daunting since it involves revamping transportation and urban planning (traditionally government functions) as well as redesigning jobs (typically a private sector endeavor) and preventing elder abuse, physical, mental, and financial. The Intergenerational Clubs in Viet Nam are reportedly very successful and represent a step in the right direction. A City for Seniors in Geneva serves as the ultimate senior center, providing opportunities to socialize, to take training courses, to participate in seminars and debates, and to access information. Norway has adopted “universal design,” going beyond ramps and elevators for those with disabilities to maximize accessibility and usability for older people. And there are a few programs in the US that made it into the WHO report, examples of initiatives that are worth promoting such as Experience Corps, which places volunteers in elementary schools to stimulate reading.

WHO’s "next steps" form an ambitious program. The report identifies four priority areas: aligning the health system with the needs of the older population (shifting the emphasis from acute to chronic diseases and from individual doctors and nurses to interdisciplinary teams); developing a long term care system (involving both home care and institutional care); creating an age-friendly environment (re-making much of the societal infrastructure); and improving the way we measure success (to facilitate monitoring and understanding).  

A number of countries have taken the first steps in the right direction: Age Well is a community-based peer-to-peer support program in Cape Town, South Africa. Older individuals are trained to provide companionship and social support for others in their community, and to identify needs and make referrals to the relevant health care or social service agencies. The program reports 60% improvement in measures of well-being among participants. Live and Age Together (Vivre et Vieillir Ensemble) is an ambitious undertaking in Quebec that brings together local and national government, the private sector, and families to develop a comprehensive approach to support older adults.

We can do all that WHO advocates. We can do it for the right reasons—because it would improve the well-being of a large and growing segment of the population; or for the wrong reasons—because it would, on balance, be less expensive to do it than not to. But that’s the beauty of the WHO proposal: it should appeal to the left and the right, the rich and the poor, the young and the old, in all countries, whatever their politics.

I stumbled on it purely by accident. I was looking for a picture to illustrate "diversity" for a talk I am preparing, and I seemed to remember that the World Health Organization had some beautiful photos in its earlier reports. Maybe what I liked best about those photos is that they capture the beauty and the humanity of their subjects without insisting that everyone smile for the camera. As it turns out, I didn't find what I was looking for but I discovered that on the very day I was searching, the WHO released a brand new report. It doesn’t have a very snazzy title—it’s called World Report on Ageing and Health—but it’s a remarkable and inspiring document. 

Not surprisingly, none of the major US newspapers breathed a word about its release. Maybe the reporters just haven’t had time to go over it: it is, after all, 260 pages. Or maybe they figure that what’s happening in the rest of the world isn’t terribly germane to the US. Perhaps--and I suspect this is the real reason--the media don't want to think about aging. In fact, the report is brimming with fascinating observations and interesting insights, many of which are relevant to the United States both in terms of our own aging population and in terms of national security. There is so much in here worth commenting on, that I think I will devote more than one blog post to the report. Let me begin by sharing some of the most astonishing things I learned in the first half of the report.

The report begins by suggesting that rather than thinking about expenditures on older people as pure costs, they should be seen as investments. It points to a study done in the UK a few years ago which calculated that if you put everything that the government spends on old people in one column (pensions, health care, other social welfare programs) and you put the contributions of older people in another column (taxes, consumer spending, work), you come up with a positive balance. At least in England, the net contribution of older people amounts to 40 billion pounds per year.

One of the most startling differences between this new report and its predecessor is that today's version defines healthy aging as the process of developing and maintaining the functional ability that enables well-being in older age. iI like that. All health care systems in all countries, the authors argue, should have as their single goal fostering the functional ability of older people by supporting and maintaining their intrinsic capacities and by enabling those with diminished functional capacity to do the things most important to them. This is a marked improvement, in my view, from the last major WHO report, Active Ageing, which came out in 2002, that talked about "optimizing opportunities for health." Then, health was the ultimate objective; now, health and healthcare are means to an end and that end has to do with the ability to function in society.

The description of what health in older age looks like in different countries is both intriguing and sobering. My attention was drawn to a single chart showing the percent of the population age 65-74 and the percent age 75 and older with limitations in one or more activities of daily living, by country. Only a handful of countries were listed. But the gap between the worst off and the best off was shocking—as was the revelation of who occupied the extremes. In first place is Switzerland, with fewer than 10% of the 65-74 year olds suffering a limitation in function and fewer than 20% of those over 75. In last place is Russia, with 60% of the younger old and 80% (that’s not a typo) of the older old reporting at least one ADL deficit. I haven’t quite figured out how this relates to Putin’s policy in Ukraine and Syria, but I suspect there’s a connection. There's something very rotten in the state of Russia.

On a more optimistic note, the chapter on “Health Systems” gives some uplifting examples of countries that have introduced novel approaches to improving the well-being of their older populations. Ghana is making an effort to harness its well-established system of community health workers to meet the needs of older people. And Brazil has begun integrating aging into its national family health strategy: it is using multidisciplinary teams comprised of physicians, nurses, and physical therapists, psychologists, nutritionists, occupational therapists, and others to work in community centers and to go into patients’ homes to deliver care.

More to follow…

And the Winner is...

It was fascinating to see how different media outlets responded to the latest “Globe Age Watch Index.” CBS News, which may have had rankings on the mind, given that US News and World Report just released its 2016 college rankings, leaves us dangling, entitling its article, “10 Best Countries to Live in for People Over 60.” The New York Times worries about all those countries that didn’t make it into the report—98 of them, accounting for just under 10% of the world’s population, leading off with the somewhat cryptic “Older People are Invisible in Key Data.” And the Guardian collapses the entire 29-page report to one number, telling us “It’s official—Switzerland is the Best Place to Grow Old.” So what exactly does the report say and what is there to say about it?

The rankings are based on four measures that the report’s authors say represent core issues of concern to older people. These are income security (which is a function of pension coverage, poverty rate in old age, and standard of living); health status (which is based on life expectancy at age 60, healthy life expectancy at age 60, and psychological well being); capability (which is defined in terms of employment level and educational status of older people, meant to serve as proxies for engagement and human capital); and enabling environment (which is assessed based on access to public transportation, physical safety, and social connections).

What the report finds is that among the 96 countries for which sufficient data was available, twenty are in the top quintile. The US is number 9, with Switzerland, Norway, Sweden, Germany, Canada, the Netherlands, Iceland, and Japan ahead of us, though not by much. The composite ranking is much less interesting than the component sub-scores. If you look beyond the overall ranking, you find that the US is 29 in income security (which would eject it from the top quintile if that were the sole indicator); it is 25 in health status (diito), and 17 on enabling community. In fact, the only area where the US performed very well was capability—which reflects the fact that it measures employment in people aged 55-64, and Americans seldom retire early unless they’re compelled to. So the picture for the US isn’t exactly rosy. What would be more interesting would be to look at similar indices for people who are over 70 (or at least for people over 65).

But the really important message isn’t how the US looks, however sobering that might be. The crucial message is that the rest of the world isn’t doing so well and the gap between the elderly in rich countries and those in poor countries is growing. Also disturbing although hardly surprising is how poorly countries are doing that are in conflict zones, countries including Afghanistan, the West Bank and Gaza, and Iraq. China, which is facing an imminent explosion in the size of its older population (and a dwindling supply of younger people to take care of them), is smack in the middle of the distribution, at 52. Greece, which is economically if not physically under siege, is way down at 79. Also in the fourth quintile, along with Greece, are Ukraine (73) and Russia (65). 

Yes, there is quite a bit of missing data here (though we can guess that the elderly aren’t doing well in Syria and Yemen and many of the other places that didn’t provide information) and yes, we can quibble with the specific measures that were used, although the basic categories seem reasonable. And in general, I’m not a fan of rankings (see for example, my commentary about Nursing Home Compare). But if used to identify which areas are in particular need of attention, I think the report is useful. For the US, that means health status and income.

How Much Good Could the WHCOA Do if the WHCOA Could Do Good?

A few weeks ago, I blogged about the upcoming White House Conference on Aging. This once-a-decade event took place last week. What, if anything, did it accomplish?

It was a modest affair, attended by a mere 200 invited delegates (though observed on line by 600 “watch parties”) that was more of a highly scripted performance than a platform for hashing out policy recommendations. This was no surprise, as Congress never allocated funds to support the event, so that it took place at all is something of a miracle. For all its limitations, it did accomplish something.  It was of symbolic significance, a way for the White House to affirm that the health and well-being of the older population are a concern for the entire society. It was also a forum for presenting recommendations for what people outside the federal government can do to address important public policy issues—given that Congress refuses to do so.

The Conference was of symbolic significance: it was hosted by the White House and the President actually made an appearance, addressing the attendees. And it turned to groups other than Congress to implement policy. In particular, it turned to state government, to the nursing home industry, and to the corporate world. State governments were exhorted to adopt 401K type savings plans for older people—a corresponding initiative, incidentally, failed in Congress. The nursing home industry will be charged with implementing a lengthy set of new rules proposed by the Centers for Medicare and Medicaid Services designed to improve quality of care in nursing homes. This means the nursing homes will have to pay for the enhanced training for nurses and nurses aides that the regulations would mandate as well as infection control committees to monitor antibiotic use and a host of other mandates. And corporations were given shining examples of creative technological approaches to the problems of aging: the ride-sharing service, Uber, detailed a new program that will offer older people discounted or free rides and training in using its smart phone app; Philips announced the creation of its “AgingWell Hub,” a collaboration with caregivers, older adults, academics, and companies  to identify new technologies and services that promote successful aging.

All in all, the Conference gave a boost to ongoing efforts in its four main topic areas: healthy aging, long term services and supports, elder justice, and retirement security. It was not an opportunity for brainstorming or for developing bold, radical new ideas. But it was a pragmatic approach to a pressing problem, undertaken with a paltry budget. And maybe, just maybe, Congress will be moved to do more in the coming years. After all, the average age of the current senators is 62, which means that before their term is over, the majority will be eligible for Medicare.

A longer version of this post appeared on the bmj blog. 

Compare and Contrast

I’ve long wondered how the US compares to other developed countries in providing medical care for older people. Our overall performance in the health care domain, when compared to the achievements of countries such as Australia, Canada, France, and Switzerland, has regularly demonstrated deficiencies —but many of these are related to the enormous number of uninsured individuals in the US. Seldom were people over 65, who in the US are almost all covered by Medicare, considered separately. At last, the Commonwealth Fund, which has carried out many of the previous surveys, looked into the situation for older adults. The results are illuminating.

First, the good news. The US is not at the bottom of the list on all of the indices, just some. Compared to the other 10 countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the UK), the US did quite well in a few areas. Older Americans rarely had to wait over a month for an appointment to see a specialist (only 14% reported such a long wait, compared to more than half of the respondents in Canada and in Norway). Fewer American elderly patients reported problems related to discharge planning after hospitalization—issues such as inadequate follow up or lack of information about their medications (28% did have problems, however, but this compares favorably to 70% in Norway and 67% in Sweden). And despite all the discussion in the US about the lamentable state of advance care planning, far more American older patients reported having had a discussion with someone about the care they would want if they became very ill and could not make decisions for themselves than did their counterparts in other countries (78% of Americans said they had had such a conversation, compared to 20% in Norway and 12% in France). The majority of Americans (67%) said they had designated a health care proxy, whereas the percentages were below 10% in Scandinavia and in the 25% range in New Zealand, Switzerland, and the UK. 

And then the bad news. Despite universal coverage, a sizable fraction of older Americans have substantial out of pocket expenses for health care, expenses that they often cannot meet: 19% said they had cost-related access problems in the past year, 21% said they had out of pocket expenses of $2000 or more, and 11% said they had trouble paying their medical bills. The corresponding figures in all the other countries were far lower except for Switzerland, where patients reported high out of pocket expenses but said they did not have problems paying them. In addition, nearly a quarter of American older patients reported that test results or records were not available at their appointment or that duplicate tests were ordered; this occurred far more rarely elsewhere. Getting a next day appointment when they were acutely ill was difficult for Americans, making them worse off than patients in France, Germany, the Netherlands, New Zealand, Switzerland and the UK—and leading to excess use of emergency rooms.

Finally, the surprising news: older Americans reported higher rates of chronic disease than anyone else: fully 87% said they had at least one of seven major conditions and 68% had at least two. By contrast, only one-third of older adults in the UK said they had multiple medical problems. Either Americans are more knowledgeable about their medical problems (the entire survey depended on self-report), or Americans are just sicker.

Interestingly, all the patients interviewed were pretty happy with their medical care: most everyone felt the doctor spent enough time with them and that they had a plan for self-management of their disease.

So what should we make of all this? The report is based entirely on computer-assisted telephone interviews of a random sample of people 65 and over. Relying on self-report may give a biased view of the medical care these patients actually received. But at the very least, the report offers the opportunity to look at what’s different in the health care systems in which patients are very satisfied with their care. England, for example, outperformed the US in self-management of chronic conditions and in England, the vast majority of primary care practices used nurse case managers or navigators for the patients with the most serious problems. France, which had particularly good care coordination, has a special program that incentivizes primary care physicians and specialists to develop shared care plans. In countries with better access to care, it is either free at the point of service or free for most chronic conditions, or subsidized for low-income individuals. 

If we have the humility to acknowledge that we’re not always the best, maybe we could learn something from our friends.

The Five Percent

It’s a dirty little secret that nobody other than professional geriatricians and palliative care doctors seems to know. But inside those circles, most everyone is aware that palliative care is an up and coming field that has tripled in size since 2000, while geriatrics is floundering, with fellowship training slots going unfilled in recent years and the number of board certified geriatricians declining. So an editorial in the Journal of the American Geriatrics Society advocating that the two disciplines work together to promote a joint agenda set me to thinking: why the difference? 

A slew of factors have contributed to the success of palliative care. As Dr. Diane Meier points out in her editorial, the decision to push the field by “making the business case” to hospital CEOs rather than by focusing on getting NIH research funding was crucial. The creation of CAPC, the Center to Advance Palliative Care, which focused on leadership training and skills development, was a brilliant innovation. But I couldn’t help wondering whether the different trajectories of palliative care and geriatrics, which both address the needs of the 5% of the population who are the sickest—and who use half of all health care resources—could be traced in part to different attitudes toward the old and toward the dying. An article by geriatrician Dr. Louise Aronson in a new series of groundbreaking articles on aging in the Lancet suggests attitudes matter. 

Dr. Aronson quotes the comments of Dr. Robert Butler, in many ways the founder of contemporary geriatrics, that “aging is the neglected stepchild of the human life cycle.” Writing 40 years ago, Butler made the case that “ageism” allows people to distinguish themselves from older people, to see themselves as safe from the debility and decline that afflict many in the final phase of life. Aronson tells several anecdotes to emphasize that the disdain for old people persists in medical circles today: a surgeon who laughs at a student who says she wants to go into geriatrics and jokes that the “disease” the student will specialize in is “constipation;” a senior physician joking that the best way to avoid the adverse consequences of hospitalization in the elderly is “never to build nursing homes within 100 miles of hospitals.”

I remember that my decision to do a fellowship in geriatrics was met with the same mix of derision and incredulity 30 years ago. Another young doctor in my medical residency program gave me an extremely backhanded compliment: “But you’re very smart,” she said, “so why would you go into geriatrics?” Could it be that palliative care is thriving because we are ready to face dying but geriatrics is struggling because we are unwilling to face what comes before the end?

Aging is one of the greatest challenges faced in the world today. Throughout the world, people are living longer. Falling fertility rates and rising life expectancy have led to an aging population in the developed world, but the same phenomena are striking the developing world with a vengeance: in the US, it took took 68 years for the proportion of the population over age 65 to double and in France it took 116 years—but in China, it will happen over a period of 26 years and in Brazil in a mere 21 years.  The demographic shift has been accompanied by a shift in the “global burden of disease:” in 2010, 23% of the total disease burden in the world was attributable to disorders in people over age 60. The most burdensome disorders afflicting our aging world include heart disease, stroke, chronic lung disease and diabetes, as well as lung cancer, falls, visual impairment, and dementia. The good news is that we already know a great deal about what we need to do to increase the “lifespan,” as one of the commentaries in the Lancet series calls the length of time that an individual is able to maintain good health. 

We need to use a conceptual framework that focuses on functioning rather than on disease. We need to build and support an appropriately trained workforce—both formal and informal (ie family) caregivers. A comprehensive public health strategy must taken into consideration the physical and the social environment. It needs to be grounded into an approach that begins with comprehensive assessment, elicits patient preferences, and implements a treatment plan that is continuous, coordinated, and multidisciplinary. So if we know what to do, why don’t we do it?

The barriers to a global strategy for aging are many. They include a health care system that focuses on treatment of single diseases in isolation—even though most older people have “multimorbidity” and following guidelines for single diseases leads to over-treatment and excess costs. They include social factors, such as inadequate income protection and lack of caregivers. They include lack of knowledge—as the incidence of heart disease falls and treatment of cancer improves, a larger and larger percentage of older people will die of dementia, a disease with no known treatment. Currently, 44 million people have dementia world-wide, and that number is projected to rise to 136 million by 2050. But perhaps the greatest barrier is ageism, the belief that poor health is inevitable, that all interventions are ineffective, and that better outcomes, even if they can be achieved, are not inherently valuable. 

We need to tackle the global challenge of aging. The World Health Organization has taken an important first step: at the World Assembly last May, it agreed to prioritize work on aging, to develop a “World Report on Ageing and Health,” and then to generate a Global Strategy and Action Plan.

But it cannot just be the WHO who cares about aging. We all need to care.