Wednesday, August 26, 2015

Is work life balance a first-world privledge problem, or not?

by: Alex Smith, @AlexSmithMD

In geriatrics, and to a much greater extent palliative care, work/life balance is recognized as critical to finding meaning in your work, to being at your peak at work and at home, and to avoiding burnout.


So last week I read with fascination a Washington Post story about pilot program at Stanford that supported physicians work/life balance.  Here's the brief story in bullets:
  • The powers at Stanford realized that many women were dropping out of academic medicine, despite generous leave policies, benefits for part time work, etc. They wondered why. 
  • They hired a firm to investigate.  The firm concluded that the at Stanford culture dictated "all-out devotion to work, all the time."  No one was using the generous family-friendly policies.
  • People were doing all sorts of unfunded work that ate huge chunks of time: mentoring, committee work, extra shifts, etc.
  • Stanford started a pilot program where physicians and basic scientists could use credits from the unfunded work to pay for services such as delivered meals, housecleaning, and assistance with grant writing.
  • The program, per the report, was enormously successful at improving job satisfaction.
My first reaction to this was elation.  Just offering generous policies and flexible scheduling is not enough.  You have to come close to forcing people to attend to their home life.  You have to align your policies to support those who want to work really hard, choose not take the leave, yet still desire a rewarding home life. 


So my bubble of elation was somewhat burst upon reading this reaction by Karen Sibert, an anesthesiologist at UCLA and mother.  You should go read the whole post here, which I will quote briefly:
  • "“work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white."
  • "Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague.When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working."
  • On the Stanford program: "The sheer paternalism of the Stanford program is breathtaking. The assumption, apparently, is that Stanford faculty can’t be trusted to manage their own lives inside and outside of work."
Well.


Dr. Sibert makes some valid points here.  And yet something seems a little off-base about her argument.
  • We should not set our standards for what physicians can be concerned about based on how we treat worst-off groups.  Those who are in less privileged positions should be equally invested and outspoken about work-life balance.  They have at least equal claim to concerns about work-life balance.
  • In fact, I suspect many people who are not in positions of privilege and work long hours, similar to physicians, do worry about it.  They just don't complain about work-life balance to physicians. 
  • I hired a guy in a slim battered pickup truck, such as the one Dr. Sibert describes, to work on my garden.  Because I work all week, I arranged to meet him on a Saturday.  My first preference would have been Sunday, but he was clear: "I work all week, Saturday's too.  Sunday is for my family."  Work life balance.
  • Do nurses really not have any dialogue about work/life balance?   The ones I know well talk about it.  A lot.
  • Some of the physicians I know who are most concerned about work-life balance are not white. 
I suspect that work life balance is a universal concern, not unique to physicians.  Certainly, there is a spectrum that runs from legitimate concern to whining.  Whining sounds particularly grating when it comes from the privileged class.


We could claim exception because we're in geriatrics and palliative care, and are thus at risk for higher rates of burnout due to the exhausting emotional intensity of our work.  But let's set that aside for a moment.  That's the easy road. 


For physicians as-a-whole, where do you think concerns about work-life balance fall on the spectrum of legitimacy/whining? 
Read more »

Saturday, August 22, 2015

Why you got to be so rude: the impact of rudeness on the performance of medical teams


A fascinating study came out in Pediatrics recently on the impact rudeness plays on the performance of teams that I just couldn't help but write about (partially because I cant get that song out of my head from the video at the bottom of this post).

Enough about you Eric, tell me about the study

Ok. Let’s break it down real quick. The authors took 72 Israeli NICU professionals organized into 24 teams and put them in a training simulation involving a preterm infant whose is getting sicker due to necrotizing enterocolitis. These teams were evaluated in their performance in the simulation by 3 independent judges who used structured questionnaires to assess diagnostic performance, procedural performance, information-sharing, and help-seeking.

Now here is the rub. Before the start of the simulation a "visiting" head of an American ICU joined via webcame to observe and comment (While the article didn't include picutres, I’m thinking this person had a mustache, maybe like Ron Burgundy). The teams were then randomized to either have this expert express either mildly rude statements completely unrelated to the teams’ performance or just some neutral comments. The mildly rude statetments from the US expert included:
  • Prior to the start of the simulation, the expert told participants that he had already observed a number of groups from other hospitals in Israel, and compared with the participants observed elsewhere, he was “not impressed with the quality of medicine in Israel.”
  • During a break 10 minutes into the simulation, the US expert was asked if he had any comments to which he replied that while he liked some of what he observed during his visit, medical staff like those observed in Israel “wouldn’t last a week” in his department.  He also said that he hoped participants could improve and learn more from the workshop, he also hoped that he would not get sick while in Israel.

What did they find?

Teams exposed to the mildly rude comments than to the neutral comments from the “foreign expert” had significantly worse diagnostic scores (2.6 vs 3.2 [P = .005]) and procedural performance scores  (2.8 vs 3.3 [P = .008]).  Furthermore, rudeness negatively influenced team information sharing and help-seaking.

But is this really a study of rudeness?

For me the biggest limitation of this trial is whether it was truly rudeness that had the negative impact, or whether it was other aspects in the expert’s statements that had the impact.

Lets start with whether the comments were truly rude. Whether an action is rude depends on whether an action complies with the social norms or etiquette of a group or culture.  So what is rude to in a medicine culture may not be rude in a surgical culture.  The study apparently assessed perceived rudeness.  What they found was the rude expert as compared to the control expert was more rude on a 4 point rudeness perception scale. So, I think it it is safe to assume that he was rude.

The statements though were also judgmental. It may be the passing judgment on others (as well as disparaging others) may adversely affect a teams performance, especially in situations where they are being evaluated like a simulation.

Take home point

Given these limitations, it doesn't really matter in the end when it comes to the take home: don't be so rude or judgemental or disparaging, it may impact your teams performance.

by: Eric Widera (@ewidera)

Read more »

Friday, August 21, 2015

Lawmakers rush to reintroduce End of Life Options Act, but haste makes bad policy



By: Laura Petrillo, MD (@lpetrillz)

The End of Life Options Act, which would legalize physician-assisted suicide, was stalled in the California legislature earlier this summer and seemingly shelved until next year. But in a surprise move, lawmakers introduced a new bill with the same purpose on Tuesday, during a special session on healthcare financing called by Governor Brown. The new bill would bypass the Assembly committee where SB128, the former bill, was stalled for lack of support.

The issue that lawmakers are trying to rush through the legislative process is not a trivial one— the bill would give physicians the power to prescribe medication with lethal intent to terminally ill patients, a fundamental shift in the role of medicine to date. This is an issue that deserves deep contemplation, expert and community input, and thorough vetting to ensure the safety of everyone who might be affected. Instead, the lawmakers found a way to charge ahead in a special session and bypass the members of the Assembly who had hesitation about the bill.

Geripal community, whatever your philosophical views on assisted suicide, take a moment to think about how the most vulnerable members of our society might be at risk if assisted suicide were legal in your state, and if you have concerns, speak up now. Many states have bills that have been introduced in the past year to ride the Brittany Maynard momentum, though none has successfully become a law, yet.

Here are the groups of people at greatest risk, should assisted suicide become legal under laws modeled after the Oregon Death with Dignity Act:

Older adults. Under the California SB128, the burden of ensuring that patients are acting autonomously, have capacity to make decisions, and are free from coercion, falls to the physician who receives the patient’s initial written and oral requests. At the moment, the bill states that requests must come from individuals, not their surrogate decision makers or advance directives, though there is a troubling clause that individuals can communicate “through a person familiar with the individual’s manner of communicating,” which could mean anything. There is no discussion of what to do in the case of cognitive impairment or dementia, which may present subtly in conversation or on exam, and there are no requirements for assessment of the patient’s mental status or oversight at any point after the medication is prescribed, leaving patients open to coercion from family or caregivers as their disease progresses. For a fascinating story that illustrates how dementia muddies the timing of a fully autonomous exit, check out Sandy Bem’s story.

Lonely adults. In the Netherlands, where assisted suicide and euthanasia have been socially acceptable for longer than in the U.S., the condition of terminal illness, defined in SB128 as a doctor’s estimate of prognosis six months or less, is not the only reason that people can choose to end their lives. In a study that came out last week from a Netherlands euthanasia clinic, 6.8% of patients whose requests for euthanasia were granted had the only “medical” condition of being “tired of living,” and the type of suffering named by 49% of recipients was loneliness. The slippery slope argument is often dismissed, but prominent ethicists Barron Lerner and Arthur Caplan warned that “the European data are particularly relevant for the United States.” Indeed, in Oregon, an amendment was proposed to the Death with Dignity law earlier this year to extend the prognosis criteria from 6 to 12 months, underscoring the permeability of the hard line for what constitutes a terminal illness.

Disadvantaged socioeconomic groups. Despite the increased access to healthcare from the Affordable Care Act, patients and their families are still financially burdened by their medical care, and the proportional effect of this is greatest on the poorest members of society. Data from Oregon and Washington indicate that 40% of people who use assisted suicide express concern about being a burden on family, and 3% of people cite the financial implications of treatment as a reason for seeking assisted suicide. The response to this stress should not be to hand over lethal medication, but to redouble our efforts to increase access to good quality care for dying patients (and for everyone, all throughout life). The fact that the new assisted suicide bill was introduced in a healthcare financing session brings to mind the terrible implication that assisted suicide could save money for the entire healthcare system, though that was unlikely the intent of the lawmakers.

Patients with psychiatric illness. As with decision-making capacity, the burden of evaluating patients for mental illness falls to the original provider who receives the request, and the language in the bill is casual: “If there are indications of a mental disorder, the consulting physician shall refer the individual for a mental health specialist assessment.” Unfortunately, in Oregon, despite the finding of a 2008 study by Ganzini et al in BMJ that 26% of Oregonians who requested assisted suicide met criteria for depression, only 3 out of 105 people who died by assisted suicide in Oregon in 2014 were referred for a psychiatric evaluation. Besides the depressed individuals, the legalization of assisted suicide puts the greater community of people suffering from mental illness at risk, by condoning the idea that suicide is acceptable when people have decided life is not worth living for them. Suicide contagion is a real phenomenon, and there has been a concerning rise in the rate of all suicides in Oregon since legalization of assisted suicide. For a dramatic view of how legalization of assisted suicide can change a society’s attitude toward protection of people with mental illness, I recommend this story about euthanasia in Belgium.

Proponents of “Death with Dignity” and SB128 believe that assisted suicide is for a select group of people who want to make an independent, personal choice to control the circumstances of their death, which would otherwise be a gruesome process with inevitable suffering. For a public already anxious about death, and unfamiliar with its final stages, this can be compelling. But this is an unrealistic portrayal of death— the vast majority of patients can actually achieve the level of control and relief from suffering that they hope for through existing hospice and palliative care services. Proponents still insist that even with adequate access to palliative and hospice care (which not every patient yet has), there is a role for assisted suicide for some patients. That may be— but we owe it to our patients to think about at what cost. Evidence from Europe and even Oregon demonstrate that introducing the option of assisted suicide opens a pandora’s box of far-reaching consequences, with the greatest implications for our most vulnerable members of society.

We have an obligation as healthcare providers to keep our patients safe, and we can’t afford to rush the decision about whether assisted suicide is sound public policy. Please use your voice. To take action in California, write to your Assembly member (find yours here) and Governor Brown.

Read more »

Tuesday, August 18, 2015

Choice and Control at the End of Life – The 3 Wishes Project

One of the advantages of getting behind in reading medical journals is seeing links between articles when I finally try to catch up in one mind-numbing session.  In reading some articles from this past week’s lineup of journals (which admittedly doesn’t count as “falling behind”), one theme was the choice and empowerment that clinicians do and don’t provide to patients in late life. 

One article in particular caught my eye: a piece by Cook et al in Annals of Internal Medicine on the 3 Wishes Project.  This project encouraged patients dying in the ICU - and their family members and clinicians - to generate and implement at least 3 wishes, for example bringing personal mementos into the hospital room, renewing wedding vows at the bedside, recreating a date night in the ICU, or allowing a mother to lie in bed with her son as he died.  Not surprisingly, the project was well-received, with mixed-methods approaches finding that it helped improve patients’ dignity, give their families a voice, and foster clinician compassion.  But, I found several other findings particularly interesting. 
  • Nearly all (98%) wishes were implemented. 
  • Half of the wishes (48%) were implemented after the patient’s death.  These included memorials, charitable contributions to causes that were important to patients, and the championing of those causes.  
  • The majority of wishes (52%) came from clinicians.  As the article stated: “Based on their knowledge of the patients or families, clinicians may have suggested wishes, which often prompted families or patients to think of wishes themselves.” 


What do these finding mean?  My take is:
  • 98% of wishes were implemented. ==> We can do this.
  • Half of wishes were implemented after the patient’s death.  ==> When I think about how to improve end-of-life care, I usually focus on improving comfort, dignity, and meaning in the time before the patient dies.  Perhaps I have underappreciated another critical element: helping patients and families continue the meaning of patients’ lives after they are gone.
  • 52% of wishes came from clinicians. ==> As clinicians, we can and should be active in helping patients and their families craft and implement their wishes.


This is likely old hat to palliative care physicians, but a good reminder to the rest of us about what we can and should do to help patients and their families at the end of life.

by: Mike Steinman





Read more »

Monday, August 17, 2015

Is antiepileptic therapy indicated for primary prevention after an ischemic stroke?

Mrs. C is a 79 year old nursing home resident woman who suffered an ischemic stroke about 10 months ago. She also suffers from depression, multiple frequent falls, dementia with behavioral disturbances, and psychosis. She was started on Levetiracetam (Keppra) 750 mg by mouth twice a day for seizure prophylaxis in the hospital after her stroke. The consulting neurologist at the nursing home recommended continuation of this antiepileptic for seizure prophylaxis. Thinking about how can I optimize her care, I wondered if in older adult patients with history of an ischemic cerebrovascular event, are antiepileptic drugs indicated for seizure prophylaxis?

To find the answer to this Therapy question, I began my search with Pubmed Clinical Queries using the terms “older adults with stroke and antiepileptic drugs for seizure prophylaxis” looking for randomized controlled trials or meta-analyses. The result of my search resulted in a Cochrane review originally published in 2010 with an update in 2014, which included articles evaluating the effects of antiepileptics for primary and secondary prevention.

Photo by: Emilio Garcia
The most recent Cochrane review from 2014 found only one trial, a randomized controlled double blinded trial, comparing valproic acid with placebo for primary prevention of seizures in 72 adults (over 18 years of age) with an average age of 68.5 years with spontaneous non-aneurysmal, non-traumatic intracerebral hemorrhage. The dose of valproic acid used in this study was 800 mg/d (400 mg twice daily, entirely oral). The primary outcome was seizure occurrence at 1 year, based on nursing or family / caregiver report or a witnessed episode.

Seven out of 36 in the valproic acid group and 8 out of 36 in the placebo group had a seizure after 12 months follow up. These results translate to a calculated relative risk ratio of 0.86 (see table). No confidence interval was reported, but it was stated that there was no statistically significant difference between the 2 groups. Regarding adverse events, there was no increase in sedation, rate of intubation or length of hospitalization in the intervention group compared to the control group. Two participants in the intervention group experienced a mild liver dysfunction that did not warrant treatment discontinuation.



Seizure
No Seizure


Valproic acid
7
29
Risk of seizure in intervention group = 
7 / 7+29 = 0.19
Placebo
8
28
Risk of seizure in control group = 
8 / 8+28 = 0.22
Relative Risk Ratio = 0.19 / 0.22 = 0.86

This RCT was well designed and with low risk of bias (randomization, blinding, etc); nevertheless there is a possibility of a type 2 error (false negative) when a negative study is reviewed, especially one with a small sample size. We could not find details of study power calculation done by the authors to ensure a sample size large enough to detect a difference between the groups if one exists. This is particularly important to know because some of the secondary outcomes showed a trend towards a benefit from valproic acid.

In summary, the use of antiepileptic drugs after hemorrhagic stroke is of questionable value. Interestingly, there is no study that evaluates the use of antiepileptic medications in ischemic stroke (the more common form of stroke). The American Association of Neurological Surgeons and Congress of Neurological Surgeons in June 2014, in view of the lack of available evidence, recommended against the routine use seizure prophylaxis in patients following ischemic stroke, as part of their Choosing Wisely® campaign.

Back to Mrs. C
After discussing this case and without strong evidence supporting the routine use of antiepeliptic drugs for prophylaxis, we slowly started titrated off the antiepileptic drug over a period of 4 months and Mrs. C has not experienced any complications. The need for chronic antiepileptic use should be evaluated periodically in stroke patients and aspects such as side effects, risk of falls, polypharmacy, prognosis and cost effectiveness, should be taken into consideration.

By: Vanessa Rodriguez, MD, Geriatrics and Palliative Medicine fellow at Icahn School of Medicine at Mount Sinai, New York.

This post is part of the #GeriCases series, in which we discuss a clinical case in geriatrics and palliative medicine and the attempt to provide patient-centered care with the use of best available evidence.
Ravishankar Ramaswamy, MD
@RavRamaswamy
Section Editor, #GeriCases
Read more »

Friday, August 7, 2015

ePrognosis 2.0: PPS and Cancer screening



by: Alex Smith, @AlexSmithMD

The geriatrics, general medicine, and palliative care communities have spoken, and we've been listening.

ePrognosis is the website we created to help clinicians in everyday practice calculate prognosis or life expectancy.  Two things we've heard over and over about how we could improve ePrognosis:
  1. "We want the PPS!"  "The Palliative Performance Scale (PPS) is likely the most widely used prognostic scale in hospice and palliative care, why isn't it on ePrognosis?"  "ePrognosis doesn't have any really short term prognostic calculators."
  2. "ePrognosis the app in the iTunes store is great, but I'm not an apple person.  Can't you make something like that for android?"
 In response to this feedback, we're excited to announce the addition of the PPS and ePrognosis: Cancer Screening to our website.  Key features of the PPS:
  1. From the main page, you can get to the PPS one of 3 ways.  We did this in order to leverage recent validation studies that have examined the PPS in large but distinct populations:
    1. By selecting that your patient is in hospice
    2. By selecting hospital, then palliative care consult
    3. By selecting clinic, prognosis less than 1 year, and advanced cancer
  2. Outcomes from the PPS will vary depending on your selection above.  So entering the same risk information in the PPS for a patient in hospice will result in a shorter prognosis than entering the same information for a clinic patient with advanced cancer.  This is because the prognosis in the validation studies varied by score depending on the population studied (hospitalized, hospice, outpatient with cancer).  If you think about it, this makes sense.
  

Key features of the cancer screening website:
  1. You can get to the cancer screening website by clicking on the icon in the center of the page, or the link "Cancer screening" in the upper right of the main page.
  2. You can use the website on any mobile or tablet, apple or andoid.
  3. We're very happy with the new design of the cancer screening website.  Websites are increasingly going to this look, with big images and horizontal scrolling. We will soon be converting most of ePrognosis to this look.


We're listening.  Let us know what you think.  

And look for more new updates soon (spoiler alert: video of Eric Widera having a code status discussion)
Read more »

Monday, August 3, 2015

What's your favorite reference book in geriatrics and palliative care?

by: Alex Smith, @AlexSmithMD

It’s summer, and the new fellows have started. I usually post around this time about a basic concept to teach new fellows. See previous posts about:
For this post, I’d like to hear people’s opinions on their favorite reference books to recommend to new fellows in geriatrics and palliative care.

Here’s my favorite reference book for palliative care fellows: A Physician's Guide to Pain and Symptom Management in Cancer Patients, by Janet Abrahm.

The evidence base for symptom management, particularly in cancer care, is growing by leaps and bounds. That said, in the larger picture, there is still little evidence for much of what we do. Why do we choose this opioid over that opioid? Why do we choose this stimulant laxative over that stimulant laxative? In such situations, we turn from evidence to “guru” medicine.

Now, there are some people who are experts in symptom management. And then there are people who are on a higher level altogether – Jedi Knights, Zen Masters, or Gurus of symptom management.

These people, through years of practice, learning from with other experts and gurus, are repositories of a remarkable store of information. The key that separates these Gurus from other experts, in addition to a larger knowledge base, is their ability to teach that knowledge effectively to others. 

Janet Abrahm is one of two people I know at that rarified level (the other, Eduardo Bruera, I don’t know personally, though I’ve heard him teach). I was fortunate to train under Janet Abrahm during palliative care fellowship.

I’m not saying this book is all Guru medicine, because it’s not. She references the evidence, where available. But if she only referenced what there was high quality evidence for it would be a slim volume indeed.

This is my current favorite reference book, the one that I loan to fellows when I’m on service. This is my “go-to” book when I’m stumped, uncertain, or want to double check my thinking about symptom management. I’m delighted to hear Janet whispering in my ear as I read. I used it recently to look up:
  • How to treat rectal spasm- Belladona and Opium (B&O) suppositories, with topical anesthesia pre-medication prior to suppository.  Consider ganglion impar block if refractory.
  • Ketamine for refractory pain 
  • Adjuvant treatments for bone pain due to cancer (NSAIDS, corticosteroids, bisphosponates, denosumab, vertebro/kypho-plasty, radiation)
  • A chapter devoted to sexuality and cancer

The book is not without weakness. The table of contents and appendix are not great, meaning it's not as easy to "search" for specific issues or symptoms as it should be.  The long paragraph format is somewhat antiquated in today's "just give me the bullet point" world.  There could be more white space.  The penalty for comprehensiveness is a big book.

Finally, Janet Abrham is an oncologist by training, and the book focuses on symptom management in cancer care. This leaves a big void, however, for the majority of patients who do not die of cancer.  The book does include a nice section on relieving pain in older persons, and a nice figure of the PAINAD scale for assessing pain in advanced dementia.

However, at the risk of being accused of therapeutic nihilism, if the evidence for symptom management is thin but growing in cancer care, it’s a complete wasteland for other conditions. What is the best medication for chronic non-malignant pain due to osteoarthritis refractory to acetaminophen? Good luck answering that fundamental question with the evidence.  We desperately need more research in symptom management for conditions other than cancer!  And reliable funding mechanisms for large randomized trials in frail elders.

But I’m curious – what is your favorite reference book? What do you recommend to new fellows?

Note: I’m not tooting my own horn here. I’ve authored chapters for a number of geriatrics and palliative care text books and UptoDate. They’re all great books, and with the right question, I’ll turn to them for guidance. They’re just not my first choice as a reference for symptom management in everyday clinical practice, where the most challenging symptoms in the elderly I see are still due to cancer. If you’re going to promote your own work in the comments, please make sure you’re being honest about what you use as a reference!
Read more »

Thursday, July 23, 2015

Fifteen minutes of fame? Aging policy’s big week



Last week was a huge week in aging policy. On Monday, the White House hosted the once-a-decade Conference on Aging, an event that featured both new announcements and longtime advocates. And then on Thursday, the Senate passed the Older Americans Act Reauthorization Act by unanimous consent. It’s probably the most attention that aging issues have received in… well, in a very long time.

While advocates have a lot to cheer over the recent events, there is still much to be done. And without the bright, shiny spotlight of the White House Conference on Aging, aging advocates will be competing with the multitude of other issues facing policymakers and the upcoming presidential election. What can the aging community do? Here’s a few recommendations that come to mind.

The Older Americans Act’s reauthorization cleared one chamber—that doesn’t make it law. Advocates have been pushing for this reauthorization for years now, and it’s still not over even with the Senate’s unanimous vote. The Senate’s action is a huge step in the legislative process given its procedural rules. Now the House has to act, either on its own version (which hasn’t been introduced) or on the Senate bill. If it chooses to, the House can move what’s deemed non-controversial bills on a “fast track.” And on a related note…

Funding, or appropriations, still remains a challenge. The Older Americans Act (OAA) authorization expired in 2011, but again that’s not fatal to a federal program. OAA programs have continued to receive funding year after year even though their authorization expired. According to the Congressional Research Service, OAA programs currently receive nearly $1.9 billion in funding, a slight increase over the last fiscal year’s level. This year, the Senate and House appropriations committees have already proposed funding levels for these programs, but overall funding levels remain a big point of contention in Congress.

Aging is still seen through the political and policy lens of entitlements such as Medicare. Look at the President’s remarks at the White House Conference on Aging: he mentioned Medicare sixteen times. He mentioned OAA once, calling for its reauthorization. For advocates, this is a PR challenge because the Older Americans Act will never receive the attention that Medicare even though both share a fiftieth anniversary this year. Focusing on Medicare also ignores other important services such as housing, transportation, and nutrition.

Build on the momentum—aging is not going to have a moment like this for a long time. Advocates have a small window to build on the White House conference’s four themes—elder justice, long-term care, healthy aging, and retirement security—to educate both policymakers and the public that aging policy is larger than just Medicare, Medicaid, and Social Security. Further, this is the one time when federal agencies are all thinking about aging in a coordinated way, and advocates should push for them to continue these lines of communication. And they aren’t alone: the Government Accountability Office recently called for greater agency coordination and a strategic vision for supporting older adults.

by: Oliver J. Kim, Mousetrap Consulting (@mousetrapdc)

Read more »

Wednesday, July 22, 2015

A strategy to improve cardiac arrest survival: Do it less on those who don't want it or won't benefit from it


On June 30, 2015, the Institute of Medicine (IOM) released a report titled "Strategies to Improve Cardiac Arrest Survival: A Time to Act”. The aim of the report was to focus on ways to improve outcomes follow a cardiac arrest, and to the reports credit, the outcome of interest was not just survival but also function. However, if there was one sentence that best summarizes my take home from this 459 page report, it would be this one from page 219:
In some ways, these cultural shifts have been built on the belief that the system should do everything possible to save every cardiac arrest patient within the jurisdiction of the system.”
Just like this sentence, you can’t help feel the unbridled optimism that seems to permeate most sections of the report. Over and over again, the authors restate that cardiac arrest is a “treatable public health threat” and that if “treatments were more efficiently implemented on a broader basis” we “could avoid needless deaths and disability each year.”

By design, every aspect of this document is focused on ways to either increase the use resuscitative interventions or improve outcomes after CPR is initiated. This means that there is nothing on:
  • ensuring that those who don't want resuscitation don’t get it (POLST isn’t even mentioned once in the document)
  • targeting these resuscitative interventions on those who are likely to benefit 

Furthermore, advance directives and patient preferences are mentioned a couple times, but mainly around the setting of “withdrawal of care” after CPR is performed (one a side note – why the heck is IOM using the phrase “withdrawal of care”, can they not find a palliative care doctor to read this before publication!)

Unfortunately even the few instances when patient preferences are discussed, they seem to have subtle hallmarks of disapproval for those who opt against resuscitation as noted in this quote:
“Survival is never possible if care is withdrawn prematurely, but the patient’s preferences and values should always be the guiding principles in customized approaches to care.”

The icing on the cake for me is that when personalized medical care is mentioned in the document it refers not to ensuring that the patient gets that care that they want and that this care is consistent with their goals, but care that “employs genetic sequencing and other advanced techniques to customize medical care to the needs of the individual patient.”  That's just dumb.   If you want personalized medical care, start with the person and not a genetic test or some other "advanced technique" unless that technique is some type of communication skill used in a  family meeting.  

by: Eric Widera (@ewidera)
Read more »

Thursday, July 9, 2015

Secondhand Antibiotic Exposure in Nursing Homes



Antibiotics are some of the most commonly prescribed medications in nursing homes. Past studies have shown that around 2 out of 3 nursing home residents receive an antibiotic every year, mostly for urinary tract and respiration infections. While there are benefits to antibiotic use when used appropriately, there are also significant downsides to the person being prescribed these drugs: Clostridium difficile infection and diarrhea, polypharmacy, medication side effects, and the potential for future development of antibiotic-resistant organisms.

But what about those living in the nursing home who aren’t prescribed these medications, is there a risk to them even if they aren’t the ones getting the antibiotic? A recent study that came out in JAMA IM showed that not only is antibiotic use highly variable across nursing homes, but their was an association with greater harms if you happen to live in a nursing home that used a lot of antibiotics, even if you didn't get an antibiotic yourself.

The Study

The authors of the study linked healthcare datasets from the province of Ontario, Canada from 2010 and 2011. These datasets included information on nursing home residents, medication prescriptions, physician visits, emergency room visits, and hospitalizations. Nursing homes were classified into tertiles as being low, medium, and high antibiotic users based on days of use (importantly not number of treatment courses). Finally the authors assessed whether being within one of these tertiles had an effect on the individual risk of antibiotic-related adverse outcomes.

The Results

On average, 5 of every 100 days someone lived in a nursing home was a day they were also taking an antibiotic, although this number was highly variable depending on which nursing home you lived in, ranging from 2 to 20 antibiotic-days per 100 resident-days.

Antibiotic-related adverse events were more common (13.3%) in residents of high-use homes than that of medium-use (12.4%) or low-use homes (11.4%) (P< .001). And here is the kicker, this assoication remained true even for residents who didn't get antibiotics.

The Take Home Point

Inappropriate antibiotic use for the treatment of things like asymptomatic bacturia not only affects the patient, putting them at risk for adverse outcomes, but also puts at risk the entire community of residents living in a nursing home.  So next time you are asked to check a urine culture for cloudy urine, just say no to secondhand antibiotic exposure.

by: Eric Widera (@ewidera)
Read more »

Wednesday, July 8, 2015

A Giant Thank You to CMS: Advance Care Planning Has Value

Today it is time to celebrate!

Today the Center for Medicare and Medicaid Services (CMS) announced that it is taking a tremendous step to improve the care of Medicare beneficiaries and ensure that patients receive care that matches their goals and values. CMS proposing to begin payment for advance care planning!!!

The advance care planning codes appear in the American Medical Association’s Current Procedural Terminology (CPT) manual as 99497 and 99498. These consultations are voluntary on the part of the patient and the patient’s preferences are key to the process. Look for more details about how to implement these codes soon. The CMS proposed rule for physician payment can be found here.

CMS states "For CY 2016, we are proposing to assign CPT codes 99497 and 99498 PFS status indicator "A," which is defined as: "Active code. These codes are separately payable under the PFS. There will be RVUs for codes with this status." The presence of an "A" indicator does not mean that Medicare has made a national coverage determination regarding the service. ...We are proposing to adopt the RUC-recommended values (work RVUs, time, and direct PE inputs) for CPT codes 99497 and 99498 beginning in CY 2016 and will consider all public comments that we receive on this proposal.. "

Regular readers of GeriPal know the value of advance care planning (ACP). ACP leads to better care, higher patient and family satisfaction and it lowers caregiver distress.

In a call for ACP payments last year GeriPal cited:
  • There is now clear guidance to policy makers 
    • The Institute of Medicine (IOM) report, Dying In America, sends a clear message to policy makers by highlighting clinician-patient communication and advance care planning as one of the key areas of focus and recommendations. The IOM report recommends that standards for clinician-patient communication and advance care planning be developed that are measurable, actionable, and evidence-based. The report states that "payers and health care delivery organizations should adopt these standard and their supporting processes, and integrate them into assessments, care plans and the reporting of health care quality"
  • There is an evidence base for communication and advance care planning 
    • The journal JAMA Internal Medicine recently published an excellent article from the American College of Physicians High Value Care Task Force, Communication about Serious Illness Care Goals: A Review and Synthesis of Best Practices. Drs. Bernacki and Block report that communication about serious illness care preferences improved clinical outcomes without increasing anxiety, depression, or loss of hope, but did reduce surrogate distress. The practical guidance for clinicians section is a MUST READ.
  • There are resources for patients and families 
  • There are resoucrces Health Care providers can use to learn to do this well 
    • VitalTalk is a great place where clinicians can develop the skills of challenging conversations. Check out the VitalTalk clinicians section where you can view quick guides on key skills and then try the Watch, Read, Reflect sub-section to improve your skills.

Advance care planning should be considered the standard of care for excellent communication and delivering patient-centered care.

So, on behalf of GeriPal, and geriatricians and palliative care providers everywhere, let me just say a GIANT THANK YOU to CMS for taking this important step towards recognizing the value of physicians communicating with patients and learning patient preferences. Thank you!

Why don't you take a minute to let CMS know how important this is and how useful the new codes are in practice. The agency will be accepting comments over the next 60 days. (Comments can be submitted online at regulations.gov. Check the proposed rule webpage after July 15 for a direct link.)

by: Paul Tatum

Note: For more info, see the post on Pallimed by Phil Rodgers on this same subject, with a different focus. Comments can be submitted online at regulations.gov
Read more »

Tuesday, July 7, 2015

ePOLST: It's about damn time!

By: Alex Smith, @AlexSmithMD

The following is a quote from an Emergency Medicine physician I interviewed for a study about palliative care in the emergency department:
I had 2 or 3 instances that involved a very angry phone call from a primary care physician or an oncologist, who understandably had had a several month conversation with this patient, finally getting him to move to this DNR/DNI comfort measure state, and then they come in and now we have them intubated in the ICU, you know largely through miscommunication. Part of the problem involves being able to communicate effectively with people who know the patients better—their primary care providers, their oncologists— but who aren’t there at the ER at the time the patient comes in.”
This is a serious problem folks. 

We spend a tremendous amount of energy working to help patients engage in advance care planning.  We have pushed the envelope on getting patients to make plans in the outpatient setting, before they are seriously ill and having a "code status" conversation in the hospital with a doctor they've just met for the first time.

How often is all of this work for naught?  How often do the best laid plans never make it to the hospital?  How often is the patient picked up by the ambulance, seen in the emergency department, or transferred to the intensive care unit WITHOUT their POLST, DNR order, or advance directive? 

I suspect this happens far more often than we recognize.

The failure to communicate advance care planning preferences can result in a tragic misalignment in care with preferences and goals.  Such cases can be devastating for patients, caregivers, and clinicians alike. 


Compounding the tragedy of these situations is the fact that this failure is in part entirely of our own devising.  We have separate electronic health records at Kaiser, the VA, and the county hospital.  Why?  Because we encourage competition between electronic health record providers.  As a terrible byproduct, we have a failure to communicate between health systems.  And that failure is thrown into stark relief near the end of life, when someone receives the default pathway of resuscitation, intubation, and ICU transfer when they would not have wanted it.

It's 2015 people!  We should be able to solve this simple problem!  And finally, someone has decided to do something about it. 

Ryan Van Wert and colleagues from Stanford have created an electronic POLST, or ePOLST.  This is brilliant for several reasons:

1. Seamless integration into electronic health records across platforms
2. Secure cloud based storage of POLST information
3. electronic signature on an ipad or iphone of the POLST eliminates the need for ANY paper

What does this mean for our patients?  It means clinicians will be able to easily check if the patient in front of them has a POLST, and read what it says.  It means easy entry of POLST data, and ability to change it easily over time.

About damn time.

Notes:
1. They're phasing in ePOLST in a big way in Oregon.  See articles about the rollout of ePOLST here, here, and here.

2. Oregon is great because 1. They started POLST; 2. Best summer weather in the US; and 3. Best berries in the US).




Read more »

Thursday, July 2, 2015

ABIM Discontinues Requirement for Maintaining Underlying Board Certification



American Board of Internal Medicine (ABIM) has had a lot of, well, lets just say difficult press this year. There is one piece of news though that came out yesterday that should send a smile to any internal medicine physician practicing in the specialty of Hospice and Palliative Medicine and should resolve the debate that Alex Smith talked about one year ago in this GeriPal piece.  What happened? ABIM announced that it will discontinue the requirement for maintaining underlying board certification (sorry Alex, I know you already paid)!

What does all this mean?  

This means you will not have to take the re-certifying exam in Internal Medicine just so you can remain certified in Hospice and Palliative Medicine.  While there are still some good reasons to re-certify in ones primary specialty like Internal Medicine (as summed in Alex's article), there are plenty of reasons not to.  Just the cost alone is reason to celebrate as Maintenance of Certification (MOC) program fees for Internal Medicine is $1,940 on top of the $2,560 you have to pay for Hospice and Palliative Medicine.

Who should we thank?

Given the hardships that ABIM has been under of late, I for one will be sending a quick thank you to the ABIM and its CEO, Richard Barron.  I'd also like to acknowledge the work that the American Academy of Hospice and Palliative Medicine (AAHPM) staff and physician leaders (like Tara Friedman and Holly Yang) who have worked hard to advocate for this change and other workforce issues.

What about Family Medicine?

Sorry folks.  One must maintain their primary certification by the ABFM to maintain certification in Hospice and Palliative Medicine (or any CAQ like Geriatrics for that matter.)  Word on the street is that this is unlikely to change.

by: Eric Widera (@ewidera)
Read more »

Monday, June 29, 2015

A Master of Science Program in Palliative Care?

We’re in trouble.  There just aren’t enough specialists in palliative care to palliate all the suffering out there.  One estimate of provider need is over 5,000 full time employees, which could require up to 18,000 trained providers depending on the proportion of time providers devote to the practice of palliative medicine.

One important strategy to address this problem, as highlighted by the recent IOM report Dying in America is to improve the skills of all providers in the practice of “primary” palliative care. 

Historically, some physicians have turned towards palliative medicine and hospice later in their careers – perhaps out of a desire to broaden the meaning they find in their work. However, board eligibility in Hospice and Palliative Medicine now requires fellowship training.  While this is a wonderful thing for establishing the legitimacy of the field, a potential externality is further threatening the workforce supply.  Not only are there a limited number of Palliative Medicine fellowships, it is very difficult for many mid-career clinicians to obtain training without a major disruption of their lives, such as leaving their practice and/or moving. Currently there are 300-350 palliative medicine fellows in training each year; there are a limited number of opportunities for specialty training for nurse practitioners and no programs we are aware of for physician assistants.

Amos Bailey, MD, a well-known leader in the field of Palliative Medicine and a new colleague of mine at the University of Colorado has a pretty innovative idea.  He has set up a task force to prepare an application to the Board of Regents to offer a new degree program: Master of Science in Palliative Care.  This would be an inter-professional executive Masters that would be provided predominantly online (with three separate one-week on-campus intensives).  This program will be designed for the clinicians (physicians and advance practice providers) who are already working and need or desire more training in Palliative Care.  

As part of this effort, we need to gauge potential interest in such a Masters Program.  Dr. Bailey has prepared a brief (2-3 minute) survey to explore potential demand among physicians and advanced practice providers who might be interested in such a program.  [Click here for a link to the survey]

What do you think of this idea? Personally, I’m pretty sold on the idea.  Currently, the need is so great that I have no worry that such a program would undermine my board certification in Hospice and Palliative Medicine although I can see that being a concern.  We would love to hear thoughts.  Also, any help you can provide in identifying potential participants in the program to respond to our survey would be greatly appreciated. 

by: Dan Matlock, MD, MPH
Read more »