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.

Hospital at Home?

For years, I’ve been arguing that frail older patients are often better off being treated for acute medical problems at home than in the hospital. I began making this claim during my residency when I wrote about “The Ethics of Cardiopulmonary Resuscitation,” claiming that it created cognitive dissonance for physicians in hospitals to go all out for some patients and to withhold selected treatments for others. Better, I suggested, to keep those individuals who didn’t want everything under the sun, and particularly those who didn’t want attempted cardiopulmonary resuscitation, out of the hospital altogether. 

I picked up the theme during my geriatrics fellowship in a paper entitled “Adverse Consequences of Hospitalization in the Elderly," which quantified the frequency with which older patients developed iatrogenic complications, unrelated to the medical problem for which they had been admitted and found it was 40.5 percent in those aged 70 or older, compared to 8.8 percent in those under 70. And instead of suggesting that we build higher siderails—or institute the kinds of interventions that eventually were adopted by Acute Care for the Elderly (ACE) units—we try to avoid hospitalization altogether. 

Over time, increasing evidence has accumulated that many people can be cared for at home and that this approach not only decreases the chance of adverse events (including unwanted treatment), but also results in comparable outcomes. A new study in JAMA Internal Medicine  suggests a way to pay for “hospital at home” model--by paying a single fee for acute care plus 30 days of post-acute care.

The Hospital at Home model (which, unlike the study authors, I won’t abbreviate as HaH since that makes it seem like a joke) used in this study offers hospital-style care for any of 19 common medical conditions (including pneumonia, urinary tract infection, flare of heart failure, and cellulitis) in clinically stable, interested adults who have adequate home supports. Their outcomes were compared to those of contemporaneously hospitalized adults who were eligible but either declined to participate in the study or couldn’t participate because services could not be set up for them at the particular time (night time) or day (weekends) when they showed up in the emergency department.

The results were overwhelmingly positive. Patients cared for at home, when compared to controls, were much less likely to be (re)hospitalized for any reason in the month after discharge (8.6 percent vs 15.6 percent); they were less likely to go to a skilled nursing facility after treatment of the acute episode (1.7 percent vs 10.4 percent); and they were far more likely to rate the quality of their care as excellent (68 percent vs 45 percent). While 12.2 percent of the Hospital at Home patients did end up in the hospital for treatment of the acute illness, there were no differences in mortality. There were also no differences in complications such as falls or infections, but the number of either of these adverse events was too small to draw any definitive conclusions.

On the other hand, as the authors of the accompanying commentary indicate, the study was a case control study, not a randomized trial, and the “controls” were significantly different from the cases: they were younger (a lot younger—an average of 71.5 compared to 76.0), less well educated, and better functioning (55.5 percent had at least one area of difficulty in daily activities, compared to 71.5 percent in the Hospital at Home patients). However, finding that the home care patients fared at least as well and, in many instances, better than their hospitalized counterparts, even though they were older and frailer suggests that they may have more to gain by staying out of the institution.

It's heartwarming to see evidence that treating many medical problems at home is achievable without sacrificing any important benefits and to discover there are plausible ways of paying for such care. My concern is that the “hospital at home” model, while an improvement over the hospital environment precisely because it takes place in a familiar location, may bring too much hospital technology with it. I would like to have a better understanding of just what hospital at home includes. I’m reminded of the final days of Pope John Paul II, dying of Parkinson’s disease and its complications. The Pope was cared for at home—but with a feeding tube, a ventilator, and physician care. He was, for all intents and purposes, receiving ICU care at home. So, by all means, let’s make medical care available to older people at home; let’s keep them out of the hospital if possible. But that should not mean bringing the hospital in entirety to them.

Transfers Redux

Last week, I praised MedPAC for devoting an entire chapter of its June report to Congress to strategies for decreasing transfers from nursing homes to acute care hospitals. Some of the pilot projects reported had successfully reduced potentially burdensome, unwanted, and costly hospitalizations of the frail, very elderly population who live in nursing homes. So I was dismayed to read this week about a follow-up study to one of these pilots, a large, randomized controlled trial—that failed to produce any change whatsoever.

Robert Kane, the lead author, who sadly passed away several months before the publication of the article, was a prolific, influential, and thoughtful scholar of geriatrics in general and long term care in particular; Joseph Ouslander, the senior author, is likewise a giant in the field of geriatrics, who has similarly focused much of his research on long term care. Their report of the INTERACT (Intervention to Reduce Acute Care Transfers) trial, begins by observing that the core principles underlying the study are 1) early recognition and proficient management of acute conditions has the potential to prevent the progression of disease to the point where hospitalization is deemed necessary; 2) the availability of communication, documentation, and decision tools can facilitate care by advanced practice clinicians; and 3) an emphasis on advance care planning, hospice, and palliative care can lead to a higher frequency of “do not hospitalize” orders. Encouraged by the results of their non-randomized pilot study, which demonstrated a 24 percent decrease in all-cause hospitalization among residents of study nursing homes (facilities that volunteered to participate) during the study period compared to baseline, rather than a 6 percent decrease in control facilities, the authors developed a larger, randomized controlled trial to further test the effectiveness of their program. The new program relied on webinars and on line courses to educate nursing home staff and monthly phone calls for support.

The authors reported on 227,140 person-years of observation in 264 nursing homes (randomized to intervention homes, usual care homes, and usual care plus phone contact). Careful statistical analysis revealed no difference in the overall hospital admission rate, the potentially avoidable hospitalization rate, or the rate of Emergency Department visits. No effect at all.
       So was the conclusion I arrived at last week—that people living in nursing homes will forgo hospital care if they are offered a viable alternative and if they (or their surrogate decision-makers) understand both their overall health status and the perils of hospitalization—totally unjustified? Maybe. But maybe not. 

       All we know is that the essence of the project involved educating nursing home personnel to allow them, in principle, to provide more on site care. We know that core staff members, who were obligated by the terms of the study to complete all training modules, in fact only attended 67 percent of the webinars and completed only 52 percent of the online courses; they also only participated in 52 percent of the monthly supportive/feedback phone calls. We know that when push came to shove, either patients or families wanted to go to the hospital, staff members wanted to send them, or both.
       What is far from clear is whether the INTERACT intervention actually improved the quality of care available on site, whether residents and families were aware of and trusted in the improvements, or whether any staff members in fact spoke to patients and families about their state of health, explored goals of care, or offered either hospice or palliative care services. 
       Before we abandon the effort, let’s be sure that the training truly “took,” both in the sense of better capabilities (on the staff side) and of heightened awareness (on the resident and family side). As the authors acknowledge, maybe distance learning is not the right way to teach new knowledge and skills. 
       It's premature to conclude that an approach to decreasing transfers is a failure just because the educational intervention on which it is based was unsuccessful. Before making that leap, we need to be sure that the educational effort truly translates into more advance care planning discussions, more widespread detection and treatment of acute medical conditions, and institution-wide familiarity with the changes. There's still hope that better on site medical care and advance care planning will ultimately reduce the transfer rate from the nursing home to the hospital. But first we need to figure out how to provide reliable, competent, trustworthy nursing home-based treatment and then we need to develop a system of advance care planning that builds on the availability of this kind of treatment.

To Transfer or Not to Transfer

With the Senate’s attempt to repeal and replace the Affordable Care Act temporarily on hold, I turned my attention to the MedPAC report sent to Congress earlier this month, its annual report on “Medicare and the Health Care Delivery System.”  MedPAC, I once said, is one of the most-important-organizations-you-never-heard of. It is an independent group of 17 commissioners appointed by the US Comptroller General that advises Congress on the Medicare program. Some of Medicare’s most influential programs in recent years, such as the readmissions reduction program and the hospital acquired conditions reduction program, had their origins in MedPAC recommendations.

One  chapter that I found particularly intriguing was the one on hospital and SNF (skilled nursing facility) use by Medicare beneficiaries who reside in nursing facilities. Much attention has been paid to patients going from the hospital to home and back to the hospital, and a fair amount of attention accorded to patients going from the hospital to the SNF (rehab) and back to the hospital. But this section addressed a different population: the frailest 1.6 million people in America, those living in long term care facilities. It asked whether they were being appropriately transferred to the acute care hospital. As the MedPAC report noted, these are patients who often get into trouble when they are hospitalized: they are prone to falling, developing delirium, suffering from hospital-associated infections, and to experiencing the adverse effects of “polypharmacy,” the prescribing of multiple medications. These are individuals who live in an environment that provides nursing care 24/7 along with personal care, as well as access to physicians, prescription medications, and physical therapists. Surely it would be better for the nursing home residents—and for Medicare’s bottom line—if they could be treated where they live. Are they? If not, why not?

The answer is that they aren’t cared for in the nursing facility as often as they should be. The single most important factor determining if a person is treated in the nursing home or sent to the hospital is the availability of on-site medical care, both physicians (or advanced practice clinicians such as physician assistants or nurse practitioners) and diagnostic modalities (such as x-rays).

Suddenly this conclusion had a familiar ring and I remembered that 35 years ago, during my fellowship in geriatric medicine, I decided to study why nursing home residents were transferred to the acute care hospital. I spent many long hours in the emergency department of Boston City Hospital examining medical records—I didn’t stop until I had identified 100 patients who arrived in the ED from any of 22 area nursing homes. During the same period, 338 older individuals who lived in the community, in their own homes, had sought care, and these people served as controls. What I found was that the patients coming from the nursing home were remarkably similar to those coming from home in terms of their severity of illness. They were, on average, older (83 compared to 77), whiter (92 percent compared to 56 percent), and more likely to be female (64 percent compared to 51 percent). They were more apt to present with fever or a change in their mental status, both common problems with increasing age. But otherwise, the two groups looked very similar from a medical perspective. I concluded that we could increase the efficiency of medical resource utilization and promote better care if we simply improved on-site care in nursing homes. Almost exactly what MedPAC found in its analysis today.

To be sure, some nursing homes have programs in place that go a long way to rectifying the situation, and CMS has supported several pilot programs designed to avoid hospitalizing nursing home residents. These programs have several features in common: they enhance the treatment available in the nursing home by using advanced practice clinicians or providing in-service training to other staff members; and they encourage advance care planning by residents and their families to promote discussions of prognosis, preferences, and planning for future illness.

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So why, after over three decades, do we still transfer many patients from the nursing home to the hospital? Why don’t we provide more on-site medical care? The reasons are complex and include an historical lack of interest by physicians in the frailest, oldest patients as well as poor reimbursement for nursing home medical care. But fundamentally, what the enduring problem shows is that we continue to fail to recognize that people in nursing homes—and their families—do want treatment of their medical problems. They may be willing to forgo the most invasive and burdensome forms of treatment—such as ICU care, ventilator care, and major surgery—but that doesn’t mean they are satisfied with a focus exclusively on comfort. If all the nursing home can offer is Tylenol and oxygen, perhaps along with morphine or other opioids, then nursing home residents will want to go to the hospital when they become acutely ill. 

We need to offer nursing home residents a viable alternative to the extremes of comfort care only, on the one hand, or maximally aggressive care on the other. And we need to explain what the various approaches to treatment would mean for them. Only then will we stanch the flow from the nursing home to the hospital.

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Falling Down on the Job

In the sixties, physicians routinely prescribed bed rest for patients who had suffered a heart attack. Then along came the recognition that bed rest led to clot formation in the lower extremities, clots that sometimes broke off and traveled to the lungs, causing potentially life-threatening pulmonary emboli. Bed rest also led to deconditioning—when patients finally were allowed to get up, they found they were often weak and wobbly. And so bed rest was out and early mobilization was in. But now, concurrent with a vigorous attempt to prevent falls among older hospitalized patients, bed rest is back in—and with more complications than ever, as reported in a thoughtful article in JAMA Internal Medicine last week.

In 2008, in response to the observation that “injurious falls” were responsible for increased hospital costs and were clearly bad for patients, the Centers for Medicare and Medicaid Services introduced a program incentivizing hospitals to prevent falls. Currently, a fall resulting in significant injury (such as a fracture) is one of eight hospital-acquired conditions that collectively determine whether hospitals will be penalized for poor performance. To address the CMS initiative, hospitals introduced a variety of techniques designed to keep older patients from falling such as bed alarms and “fall risk” signs on the door. According to Growdon and colleagues, the result has been a “national epidemic of immobility among hospitalized older adults.”

Paradoxically, the means used by hospitals to prevent falls don’t work. Bed (and chair) alarms are ineffective—which is not entirely surprising, as by the time a nurse responds to the buzzer indicating the patient has gotten out of bed (or chair), the person is probably already on the floor. Even a multi-prong study from Australia using a variety of different approaches simultaneously was unsuccessful.

But all those bed alarms and signs on the door do achieve something, and that’s to keep patients at bed rest. And just as bed rest was bad for heart attack patients in the sixties, it’s bad for older patients today. Bed rest promotes the development of confusion (delirium) and worsens mobility, so when patients finally do get out of bed, either late in their hospital stay or after they get home, they are more likely to fall.

Growdon, a resident in internal medicine at a major Boston teaching hospital, and his colleagues at a VA Hospital in Florida and at Hebrew Senior Life, a teaching nursing home, are rightfully indignant. They advocate promoting mobility rather than penalizing falls, arguing that “although hospital falls can lead to harm, treating them as ‘never events’ has led to over implementation of measures with little efficacy for falls [prevention] yet profound contribution to immobility.” They are, no doubt, correct. But why? Why should an incentive program based on outcomes lead to the adoption of a strategy that does not lead to the desired outcome?

If CMS had used a process measure, if it had offered extra payments to hospitals that introduced fall prevention programs, I wouldn't have been surprised that it resulted in hospitals adopting programs for the sake of having something, regardless of efficacy. But instead it opted to penalize hospitals for performing poorly, which should by rights have led to hospitals choosing to take steps that made a difference. What is it about the culture of hospitals or the leadership of hospital CEOs or the knowledge base of physicians and nurses that lets them make such irrational choices?

I wish I knew the answer. In the meantime, perhaps CMS would do well to offer carrots rather than sticks, and to be specific about the kind of carrots that it likes the most. If programs that promote mobility work, directives to get patients out of bed early and to consult physical therapy—both to prevent falls and to maintain function—then it’s those specific programs it should endorse and pay for.

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Counting what Counts

A confession: I’m a data junkie. I don’t generally collect data (though I have carried out a few empirical studies) and I don’t analyze data statistically. But I am fascinated by descriptive data, which often provide  remarkable insights into how things were or how things are. 

When I was working on my latest book (Old and Sick in America will come out in October), and I wanted to know what nursing homes were like on the eve of the introduction of Medicare, I consulted the report, “Characteristics of Residents in Institutions for Aged or Chronically Ill: 1963,” put out by the US DHEW (as the Department of Health and Human Services was called then). I learned there were just over half a million people living in 16,370 nursing homes (just about the same number of nursing homes we have today) and that they stayed there, on average for 3 years. 

When I wanted to know what hospitals were like in the 1960s, I read “Trends in Hospital Utilization: US 1965-1986” and found that circulatory disease, which has been the number one reason for hospitalization from the 1980s to the present, was only number 6 in 1965. Over the period from 1970 to 1986, the number of catheterizations done each year in people aged 65 and older would soar from 8,000 (or 3.8/10,000 people) to 275,000 (or 85.8/10,000) and that CABG (coronary artery bypass surgery) would likewise jump from 0 to 125,000 (or 42.9/10,000). So periodically, I check whether the National Center for Health Statistics has released any “Data Briefs” about older people. This past February, the agency published “Emergency Department Visits for Injury and Illness Among Adults Aged 65 and Over, US 2012-2013.” It is a compelling reminder that the emergency department is a key source of health care for older people.

Focusing exclusively on illness (as opposed to accidents), the report finds that the elderly go to the emergency room often and the older they get, the more often they go. Each year, 29 percent of people aged 65-74 have at least one emergency visit, as do 42 percent of those aged 75-84, and 57 percent of those aged 85 and up. About a third of these older patients arrive in the emergency room by ambulance—highlighting the role of ambulances as another locus of health care for this population.

These numbers don’t tell us what actually happens to older people when they reach the ER, but other data give a few clues. In the ER, the elderly are very likely to have some kind of imaging procedure (63 percent do), with about half of those getting a plain X-ray and a quarter getting a CT scan. And fully 32 percent of those presenting to the emergency department with an illness are admitted to the hospital; 5 percent to a critical care unit. There’s much that is left out if we focus only on descriptive statistics: we don’t know whether these patients typically have a friend or family member with them; we don’t know if anyone asks about their home situation; we are in the dark about whether anyone addresses their goals of care or checks if they can walk or determines their mental status. But the numbers are a place to start.

What is abundantly clear is that with 15.5 million visits to the emergency department by older people every year, it’s high time we pay more attention to what actually goes on there. We have the opportunity to figure our whether the hospital is the right place to take care of whatever the problem is and, if not, how to shore up the home environment to make it a viable alternative. To answer these questions, we need to make certain that older patients routinely undergo a brief assessment of both their cognitive and physical functioning. We need to involve a family member if support will be needed at home. I would bet that if we did all this, we’d make far more headway in avoiding hospitalization and decreasing the rate of readmission than many of the elaborate transitional care programs operating today.

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