Make No Bones About It

For some time, I’ve tried to find an up-to-date list of the medications most commonly prescribed to older people. Sounds like a simple question, but getting an answer has been surprisingly challenging. Most of the available data is ten years old and that’s a long time in an era when medications go off patent, new medications are introduced, and advertising campaigns affect medication use. Much of the information is for the population as a whole—but kids really are very different from octogenarians in their pill-taking. So I was pleased to find an article in JAMA Internal Medicine this week called “Changes in Prescription and Over-the Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011.” This nationally representative sample of community dwelling older adults got its information from in-person interviews. It over-sampled certain populations to try to make sure its interviewees were truly representative. And the results are revealing.

The main finding is that fully 87.7 percent of adults over 65 (excluding those in institutions) took at least one prescription drug regularly in 2010-2011, up slightly 2005-2006. Moreover, 35.8 percent of the population take at least five prescription drugs a day (up significantly from 2005, when the rate was 30.6 percent. Lastly, there’s been a 50 percent increase in the number of people taking vitamins or supplements.

The Big Ten medications are pretty much what you would expect, though the actual percentages are a bit surprising. In first place is over-the-counter aspirin (40.2 percent); simvastatin, a cholesterol-lowering medication, is in second place (22.5 percent), and atorvastatin, another statin (formerly sold exclusively as Lipitor, before it lost patent protection) is number ten. The number three, four, six, and seven spots are taken by the anti-hypertensives, lisinopril (19.9 percent), hydrochlorothiazide (19.3 percent), metoprolol (14.9 percent), and amlodipine (13.4 percent) respectively, although it’s worth pointing out that these drugs can be used for other purposes besides lowering blood pressure—hydrochlorothiazide is a diuretic that may be used to treat heart failure, metoprolol is a beta-blocker often used to treat angina, and amlodipine is a calcium-channel blocker that can also be used in coronary artery disease. 

The remaining three drugs on the list are levothyroxine, a thyroid replacement medication, in fifth place, metformin, a drug used to treat diabetes, in eighth place, and omeprazole, a proton-pump inhibitor used for ulcers and acid reflux in the ninth spot. We are left wondering what all this means: are older people getting too many drugs? Not enough drugs? Are they getting the right medications?

Descriptive statistics cannot answer whether some patients are getting medicines they don’t need (though I’m pretty sure that’s the case) and others aren’t getting medicines from which they might benefit (probably also the case).  I think they do tell us something about the effectiveness of the strategies used to promote medications. When medications are categorized by type, statins are actually taken by just over 50 percent of older people (simvastatin and atorvastatin, drugs number 2 and 10 in the list of individual agents are not the only statins available) and anti-hypertensives by just over 65 percent of the elderly. What this tells me is that the combination of direct-to-consumer advertising, drug detailing to physicians, and  professional society guidelines--the methods used to promote statins and anti-hypertensives,at least when new drugs in each of these classes appeared on the scene--really works to change behavior. It doesn’t prove anything, but it’s awfully suggestive.

Also worth exploring is the dramatic increase in the percent of older people who take supplements. The authors of the study assert that this occurred although there is “no evidence of any clinical benefit.” I think this is a distortion. There may be little evidence of clinical benefit for some of the supplements, such as omega 3 fatty acids, but the story for vitamin D and calcium is both messier and more illuminating.

Over the years, Vitamin D has gone from being clearly necessary for strong bones, to very useful in preventing falls, to a dangerous poison, to a useless additive, and back again. Just what do we know as of 2016? We know that vitamin D is essential to human beings and we get it from sun exposure or from diet, although not many foods other than the ones such as milk to which we now add it naturally contain Vitamin D. Actually, that’s not quite accurate either, as what we get from the sun and from food is a pre-cursor of the active form of vitamin D that we need to make bones, and we rely on our kidneys and livers to perform the transformation. We also know from the National Health and Nutrition Examination Study that at least as of 2005-2006, 42 percent of adults had vitamin D levels below 20 ng/ml, which just about all authorities regard as too low. We also know that people who take megadose vitamin D as part of a fad diet, sometimes taking as much as 100 times the recommended daily dose, can get poisoned by such quantities.

The big question remains whether taking supplementary vitamin D—on the order of 800 units a day (not the tens of thousands of units taken by fad dieters)—prevents falls and fractures. Falls and fractures cost over $28 billion in older people, and that’s just the direct costs; it doesn’t include the pain and suffering and the loss of functioning and independence. The data on the efficacy of vitamin D are a mixed bag, with some studies showing strong evidence that it helps and a few failing to show any benefit at all. Putting all the conflicting evidence together, the American Geriatrics Society recommends, based on the preponderance of evidence, that all older adults, whether living in the community or in an institution, take vitamin D supplements of at least 1000 units together with calcium. Judging by the JAMA Internal Medicine article, we have a long way to go to reach this target: while 35 percent of older people do take a multivitamin (which includes 400 units of vitamin D), just under 16 percent take vitamin D alone.

The back story here is that vitamin D is cheap. No drug company is promoting vitamin D. In addition to being cheap, vitamin D has virtually no side effects (unless it is taken at hundreds of times the recommended dose). And it just might work. We should think about the ways that the consumption of cardiac medications have changed—and the ways that these changes have been achieved. We might learn something about how our system operates and how we can change the attitudes and behavior towards therapy that has a good chance of helping without breaking the bank.

Pay to Plan

When Medicare began allowing payment to physicians for advance care planning on January 1, bloggers and editorialists and columnists all commented on the new rule. Many said what a great new advance this is. Dr. Diane Meier, founder of the Center for the Advancement of Palliative Care, said it was “substantive and symbolic.” Others were more guarded. Dr. Robert Wachter of the University of California San Francisco said he expected a “modest uptick” in the number of advance care planning conversations, but did not anticipate the rule would be “transformative.” Now, an essay in Health Affairs pulls together the various comments and critiques and concludes that unless we overcome the prevailing “training deficit,” the pervasive inability of physicians to carry out such conversations, and unless we develop a health care system that allows for the implementation of whatever choices patients make, the reform will be meaningless.

The reason I didn’t blog on this topic—apart from the fact that so many other voices were chiming in—is that it seemed obvious to me that the change was exclusively symbolic. It was obvious because the truth is that doctors have been able to bill for advance care planning visits for years. Instead of using the elaborate “coding system” that most doctors use for billing purposes, in which you have to assess the level of complexity of the history, physical exam, and something nebulous called “medical decision making,” it is perfectly legitimate to bill based on time. All you have to do is state how long you spent with the patient (and family) and write that “over 50% of the visit was devoted to counseling.” If you do that, then there are no specific rules about “documenting” the physical examination and the history--your note can focus primarily on the substance of the visit, advance care planning. And you get paid more for a 40 minute office visit using the old system of time and counseling--$145.82 in 2016—than you do for a 30 minute advance care planning visit using the new code--$86.66 in 2016 (though you can also tack on an extra 30 minutes for filling out forms with the new system and bill another $75.11). 

To be sure, to use the old system, the patient has to be physically present. You have to write something in your note about the medical history, but “77 year old retired lawyer with stage 4 non-small cell lung cancer, unresponsive to chemotherapy” is good enough; and you have to write something in your note about the physical examination, but  “patient is pale and cachectic; he is hoarse and dyspneic" should suffice. The remainder of the note can address goals of care, choices about limitations of treatment, designation of a health care proxy, and so forth.

Now I don’t want to underestimate the power of symbols—especially since the effort to include any kind of mention of advance care planning in the Affordable Care Act was dead on arrival after Sarah Palin made her notorious “death panel” comments. But sometimes adopting health policies that are doomed to be ineffective leads us astray because we think we have “solved” whatever problem led to the introduction of that policy in the first place, and result in our failing to solve the problem over the coming years. Perhaps the Patient Self-Determination Act of 1990 was a legislative example of the same phenomenon—as a result of this law, every state and the District of Columbia passed some sort of advance directive legislation over the next decade, but we now recognize that this kind of “legal transactional” approach to advance care planning, rather than a more communications-based approach, doesn’t work: either people don’t use it, doctors don’t follow the directive, or the directive doesn’t apply in precisely the clinical situations that real people find themselves in. 

So yes, Medicare’s decision to reimburse doctors for time explicitly spent on advance care planning is symbolically important. But I worry that it will result in unwarranted complacence, in our checking off advance care planning reform as “accomplished” on our national to-do list. Now that would be a serious mistake.

What We Have in Common(wealth)

A year ago, I reported on an interesting comparative study of older adults: the Commonwealth Fund surveyed the health care experience of adults 55 and older in eleven developed countries and found some striking differences. Now Commonwealth has drilled deeper into its data and analyzed differences among “high need” patients in the US and eight other countries (Australia, Canada, France, Germany, the Netherlands, Norway, Sweden, and Switzerland). As usual when we compare ourselves to other countries in the health arena, we don't do so well. And as usual, the differences are enlightening.

This new study looks at patients who are “high need.” I like that term: instead of talking about “high risk” patients--patients who are really at high risk of hospitalization, institutionalization, or death because they already have a lot of needs, not because we can magically determine that they might develop needs in the future--we focus on people who have problems now. The study defines people as high need if they have either three or more chronic conditions or need help in one of their basic daily activities. I might have preferred a composite measure of chronic diseases and functional difficulties, but it turns out to be useful to separate the two for purposes of international comparisons. 

Which brings me to the first interesting observation: the US has more people with at least 3 chronic diseases than anyone else, by a lot. In the US, 42 percent of people over 65 have at least 3 chronic diseases. No other country even comes close. Switzerland is the best, at 19 percent. Everyone else is in the 20-29 range. Does this reflect actual disease rates? Or is it just that we are more thorough in diagnosis—some might say by over-diagnosing disease? The flip side of this finding is that the US performed best in ADLs—only 14 percent of Americans reported they needed a moderate amount or a lot of help, compared to 50 percent of the French. Surely this is cultural—I can imagine that individualistic Americans like to be self-reliant and don’t want to accept help; perhaps the residents of other countries are far more likely to feel that as they get older, they deserve help.

If the populations are as different as the disease and ADL prevalence variability suggests, then the differences that were found in access, costs, and coordination may be meaningless. But for what it’s worth, here's what the study found: the US has a high rate of preventable emergency room visits (19 percent, compared to a low of 4 percent in Germany); and a high rate of cost-related access problems (22 percent vs a low of 5 percent in Switzerland).

Coordination of care was poor across the board—except in France. It sounds as though French people like to have things done for them, both in terms of assistance in basic activities and having someone arrange their health care for them. They report that they actually get help with coordination; I wonder if they feel they get the help they need in other domains as well.

The US came out on top in a single area: the proportion of older people who report they have a “plan of care.” Since having a plan doesn’t amount to much if you can’t access the services you need in order to implement the plan and you don’t have anyone to help you make sure you get what the plan says you need, this accomplishment isn’t terribly impressive. But I think it does tell us something—just as in the earlier Commonwealth study, which found that American patients were more likely than their European counterparts to have designated a health care proxy, what we see here is that America does well on form. We don’t do as well on substance. That’s the disconnect we need to remedy.

All Things Dartmouth

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

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

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

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

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

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

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

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

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

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

I guess I still need to write that book.

Geriatric "Our Bodies, Ourselves?"

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

Some News is Good News

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

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

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

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

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

Integrated Mobile Healthcare

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

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

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

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

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

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

Paramedics to the Rescue?

A New Use for Ambulances--see Post on Sunday

Calling on Calculus

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

The Tipping Point

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

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

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

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

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

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

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

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

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