Wednesday, May 18, 2016

Just ask-tell-ask: Physician-Surrogate discordance about prognosis in the ICU


by: Alex Smith, @AlexSmithMD


I'm sure that all of us have encountered this scenario: the doctor thinks patient's prognosis is not good, but the family thinks it's not so bad. 


Why does this happen?  A nice study published yesterday in JAMA sheds considerable light on the issue.  Doug White and colleagues interviewed 229 surrogates of critically ill ICU patients and their ICU physicians at UCSF.  All patients were on a ventilator (breathing machine) and had been in the ICU 5 days. In 53% of instances, the physicians and surrogates held discordant estimates of the patient's prognosis, defined in this study as at least a 20% difference in likelihood of survival to hospital discharge. 


The differences were 4:1 slanted in favor of more optimistic prognostic estimates on the part of surrogates.  One particularly unique feature of this study was the use of qualitative open-ended questions to understand the reasons surrogates were more optimistic.


It turns out that there were two main sources for the discordance between ICU and surrogate perspectives:
  1. The surrogates misunderstanding the ICU physicians prognostic estimate.  The surrogates thought that the ICU physician's estimate was more optimistic than the ICU physician's actual estimate.  In other words, there was a communication breakdown between what the ICU physicians reported and what the surrogates best guess of the ICU physicians prognostic estimate.
  2. Differences in beliefs.  The quotes from the qualitative analysis were illustrative.  (1) Surrogates felt it was important to hold an optimistic estimate because maintaining hope was beneficial to the patient, "I'm trying to think positive;" (2) The surrogate knew the patient had strengths that the physician was unaware of, "[The doctors] don't know his will to live;" and (3) Religious beliefs, "[It's] up to God."
Who was right?  Both were able to predict who survived and who died better than chance alone.  The physicians were slightly (and statistically significantly) better than the surrogates.  Remembering that a coin flip or 50% represents chance alone, the surrogates were 24% better than chance alone.  The physicians were 33% better than chance alone.


Major takeaways:
  • The authors were careful to use the word "discordant" rather than "disagreement."  Disagreement would have implied a conversation about prognosis took place where the doctors and surrogates disagreed.  While 80-90% of surrogates and physicians reported that a conversation about prognosis took place, it's not clear what happened in that conversation.  My guess is the doctors "disclosed" their estimate of prognosis, perhaps being more optimistic with surrogates than they reported for the study.  It's very possible, perhaps likely, that the physicians did not ask the surrogates their own perspective of prognosis, so there was no opportunity for disagreement. 
  • Just ask-tell-ask.  The ask-tell-ask framework is palliative care bread and butter, yet the importance of using it simply cannot be overemphasized.  Some modifications are in order based on these findings: (1) Ask what the surrogate thinks the prognosis is, and what informs that perspective, including desire for optimism, sources of strength and resilience, and religious beliefs; (2) tell what you think the prognosis is and discuss your reasons; (3) ask again to see if this information has changed their views of prognosis.  See this model conversation from ePrognosis about how to use Ask-Tell-Ask.
  • JAMA publishes qualitative research?!?  Off the top of my head, I think it's been some 20+ years since JAMA published any qualitative research.  Hurrah! 













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Monday, May 16, 2016

How We Die: It’s Less about Who You Are and More About Where You Live




by: Eric Widera (@ewidera)

Doctors want to believe that they will die differently than the rest of the US. Just look at the 2011 essay written by Dr. Ken Murray, "How Doctors Die," that went viral when he described that doctors are more likely to die at home with less aggressive care. To back this belief up, studies have surveyed physicians, who state that they would want a nonaggressive, comfort-based approach to care in the face of life-limiting illness. That’s all well and nice, but do they actually die differently, or do they just say they want to die differently?

Recently, two articles came out in JAMA (and nicely summarized by Pallimed) demonstrating that in reality, doctors don't actually die that differently from others. Today, a new article published by Dan Matlock, Stacy Fischer and colleagues, adds more evidence that our preferences for a different death is unfortunately not well aligned with reality.

The Study

Using Medicare Part A claims data from 2008 to 2010, the authors compared 9,947 decedent physicians and a random sample of192,006 non-physicians. In particular they looked at days in the hospital and proportion using hospice in the last 6 months of life as primary outcome measures adjusted for sociodemo-graphic characteristics and regional variations in health care.


The Results

There was no difference between physicians and non-physicians in the number of days spent in the hospital in the last six months of life (odds ratio (OR) = 0.98, 95% confidence interval (CI) = 0.93–1.04). They were also just as likely to die in the hospital (OR = 0.99, 95% CI = 0.95–1.04) and they were more likely to use ICU or CCU level of care. Physicians did use more hospice care (46% vs 43%) and used it for longer periods of time before death (2.44 more days for physicians). Lastly, the proportion of physicians using hospice 3 days before death was different (8.1% vs 7.5%, P = .03), although it was not statistically significant after adjustment.

Why No Difference?

If you had to sum it up, it looked like physicians used a little bit more of everything near the end of life (more ICU/CCU use, more hospice use), but overall there weren’t really big differences. Just take a look at the hospice use in the last three days of life. The difference in this study was 8.1% in physicians vs 7.5% in non-physicians.

You want to see a big difference? Take a look at the newly released report by the Dartmouth Atlas and the John A. Hartford Foundation. The percentage of Medicare decedents who were enrolled in hospice care within three days of their deaths varied more than fourfold across hospital referral regions in 2012, from 6.1% in the Bronx, New York to 27.3% in Fort Lauderdale. Now that's what I call a big difference.

Another example? Days in the ICU in the last 6 months of life. Physicians vs non-physicians: 3.1 days vs 2.8. Want some real numbers? Again, from the Dartmouth Atlas report, the difference in ICU days in the last 6 months of life varies from 9 days in Miami to 1 day in La Crosse.

And therein lies the rub and something that we have learned the hard way: while doctor’s preferences may be more focused on comfort, these preferences are often less influential than the practice patterns where the care is actually delivered.
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Friday, May 6, 2016

SPRINT Trial: Should We Aim for Lower Target Blood Pressures for Older Adults?



by: Meera Sheffrin (@doctormeera)

The SPRINT trial came out about 6 months ago – it was supposed to revolutionize the way we thought about treating older adults with hypertension. “But adding *more* medicines goes against everything I believe in!” you say. Those are my feelings too, though it’s important to consider what the evidence actually shows.

Let’s break down the SPRINT trial to examine what they did, what they found, and whether it applies to the geriatric patients we care for.

But wait, don’t we already know the best blood pressure targets?

It depends on who you talk to.

Let’s look at the data we have so far: the Systolic Hypertension in the Elderly Program (SHEP) and the Hypertension in the Very Elderly Trial (HYVET) showed BP less than 150mg is beneficial. Observational studies show the lower you go, down to 115/75, the more you can prevent cardiovascular outcomes…but the observational studies don’t always show the other side: adverse effects. Really lowering blood pressure that low requires lots of medications – a cost in term of possible side effects (falls, orthostatic hypotension) and actual monetary costs.

There is data from randomized controlled trials as well: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Blood Pressure trial compared intensive blood pressure control with a goal of less than 140 to less than 120; very similar to SPRINT, but in a diabetic population. The ACCORD trial did not demonstrate a clear benefit for treatment to the lower target for on it’s primary composite cardiovascular disease outcome (Hazard Ratio 0.88, 95% CI: 0.73 to 1.06, P =0.20).

As a result, experts -cardiologist, nephrologists, geriatricians- differ on their thoughts on what the best goal blood pressure for older adults is; this study set out to answer that question.

What did the SPRINT trial do?

SPRINT was randomized, controlled trial that compared the benefit of treating of systolic blood pressure, with a goal of less than 120 mmHg to a goal of less than 140 mmHg, in in non-diabetic patients who were over 50 years old at an increased risk of cardiovascular events.  Increased risk of cardiovascular events was defined as: “clinical or subclinical cardiovascular disease other than stroke, CKD with eGFR of 20-60, 10-year risk of cardiovascular disease of ≥ 15% Framingham, or age over 75 years old.

The primary outcome was rate of the composite outcome of myocardial infarction, acute coronary syndrome, stroke, acute decompensated heart failure, or death from cardiovascular causes. This composite outcome maximizes power in the study, and consistent with other major cardiovascular trials; in fact it is same primary outcome as the ACCORD trial mentioned above.

They excluded those who had diabetes or stroke, those who had low blood pressure (systolic less than 110) after 1 min of standing, and anyone in a nursing home, only community dwelling patients were included in the trial. SPRINT also excluded people who they thought couldn’t adhere to the treatments or attend the necessary study visits.

What did they find?

There were 9,361 participants in the study, and 2,636 of them were >75yrs old! Overall 35% were woman, and the average BMI was 29. The mean baseline blood pressure was 139mmHg, and 90% of patients were on antihypertensive medications to start with.

The blood pressure lowering worked, but required more medications: Mean blood pressure in intensive group was 121.5/ 68.7 mmHg; the mean number of medications was 2.8. The mean blood pressure in standard treatment group was 134.6/ 76.3 mmHg; the mean number of medications was 1.8.
  • The main outcome (combined MI, stroke, CHF, CV death) happened in 243 (1.65% per year) in the intensive-treatment group, and 319 (2.19% per year) in the standard-treatment group. 
  • Said another way, the Hazard Ratio for intensive treatment was 0.75 [95% CI 0.64 to 0.89] 
  • The number needed to treat (NNT) to prevent one primary outcome event (combined MI, stroke, CHF, CV death), was 61 over ~3 yrs. This is impressive! CV death and all cause mortality was also reduced, NNT of 86 and 167 respectively, over 3.2 yrs.

Serious adverse events occurred in 1,793 participants in the intensive-treatment group (38.3%) and in 1,736 participants in the standard-treatment group (37.1%).

Serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or acute renal failure, occurred more frequently in the intensive treatment group. There was no difference in injurious falls or bradycardia, and actually less orthostatic hypotension in the intensive treatment group.

Can I trust these study results?

This was a well done study. They study was stopped early (after 3.26 years of the planned 5 years). In small trials this can introduce bias or exaggerate the findings, however SPRINT is large with trial with the large number of primary end points (n=564), so results are likely valid. It was open-label, so participants and investigators knew treatment assignment. Non-blinded participants/doctors could perhaps introduce some systematic bias, though hard to see how would influence results either way, and I would not discount study results based on this.

The $1 million dollar question - does this apply to the patients we care for?  Two issues here: the generalizability of the study and adverse events.

Generalizability

I think that if you took one of my geriatric clinic patients who fit the study criteria and study protocol, the study results might apply to them. This might be a 83 yo gentleman with mild CKD and hypertension, relatively healthy and active, able to manage his own meds and come to clinic for regular blood pressure checks.

Blood pressure was measured in this study as the average of 3 measurements over 5 min, taken automatically without a doctor in the room. In a separate article, the SPRINT authors note that the average blood pressure measurement could be much lower than a single blood taken by a doctor wearing white coat. This could lead to overtreatment if the just one blood pressure from clinic was used to adjust medications.

In addition, blood pressure was monitored and meds were adjusted each month – adding *and subtracting * meds to keep at goal. This much more intensive blood pressure management than is typical done in many clinics.

It is also important to remember who was excluded from SPRINT. First, no nursing home patients were included. In addition, wee can’t tell from the baseline characteristics that were reported about the participants’ level of frailty, functional status, gait speed, or ADL dependence. So I would be nervous generalizing to a frail older geriatric population, who might be very different than participants included in this study.

Adverse Events

The adverse events are very important to consider in our geriatric patients, especially syncope and hypotension! There was no difference in rates of falls (I am not sure what to make of this- maybe this was captured by syncope?). It is also important to note that randomized controlled trials are not designed to pick up all adverse events well. Even though this was large trial, more side effects could come out in observational studies/ clinical practice, and there could be more frequent adverse events when intensive blood pressure treatment is applied to real life.

My take-away:

This was a VERY well done study. The number needed to treat of 61 over 3 years is impressive. However, in our geriatric population, we have to compare the benefits to harms of syncope, hypotension (and resultant hip fractures?), and potential overtreatment due to white coat HTN. In the geriatric population, it is also important to consider the time to benefit, and incorporate life expectancy, co-morbid conditions, risks of polypharmacy, and patient values and desire to take more medications.

Based on this trial, are you going to target a lower blood pressure for some of your patients? If so, which ones? How would you explain it to them?

Read more »

Monday, May 2, 2016

Thickened Liquid Challenge Strikes Back - #ThickenedLiquidChallenge



by: Eric Widera (@ewidera)

This week's JAMA IM includes a case of a woman in her 90s with advanced dementia who was started on honey-thickened liquids for aspiration prevention.   She subsequently “refused nearly all food and thickened liquids, turning her head when nurses attempted one-on-one feeding” and was transitioned to inpatient hospice care.   What happened next?  Her diet was changed to regular liquids and she was allowed to eat her favorite foods.  Two months late her weight improved with no clinically apparent aspirations.

This is the story of thickened liquids.   As the authors of the article, Drs Wang,  Charlton, and Kohlwes, explain: “thickened liquids have become a part of routine care—some might even argue the standard of care. This has created the perception that thickened liquids are beneficial and safe for patients with dementia.”  Unfortunately, the evidence base to back up its efficacy in dementia is poor and as in this case, places patients at significant risk of adverse effects.  

We at GeriPal are personally proud that the authors described one of the most important interventions that providers can do when placed in situations like these where the “standard of care” is questionable at best: they tried it themselves.  The authors describe undertaking the “Thickened Liquid Challenge” by filming each other as they as they endured 12 hours of a thickened-liquid diet.   What was their conclusion after doing so?   Its summarized perfectly in their last sentence:
"The routine use of thickened liquids to prevent pneumonia in patients with dementia should be avoided, and diet should involve a comprehensive approach rather than a reflexive diet modification."

To learn more about the #thickenedliquidchallenge, watch/read these:




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Monday, April 25, 2016

Palliative Care and Hospice Education and Training Act (PCHETA)



Do you think palliative care is important for patients and families?
Do you think palliative care is essential for the US health system?
Then isn't it time that you acted politically to advance palliative care?

Well, this Wednesday April 27th you can join the American Academy of Hospice and Palliative Medicine (AAHPM) and other supporters of palliative care in a virtual lobbying effort to raise awareness in the US Congress about the Palliative Care and Hospice Education and Training Act (PCHETA.)  PCHETA (H.R. 3119 / S. 2748) is a bill developed by AAHPM which would expand opportunities for interdisciplinary education and training in palliative care, implement an awareness campaign to inform patients and health care providers about the benefits of palliative care and hospice, and direct funding toward palliative care research to strengthen clinical practice and health care delivery. (Access a bill summary).

The bill is supported by over 35 organizations including Geripal and AAHPM's good friends at AGS, HPNA, SWHPN, NHPCO, CAPC and many other important health care organizations like the American Cancer Society's Cancer Action Network, the Alzheimers Association, and the American Heart Association/American Stroke Association and so many others.

Thomas Jefferson once wrote that "We in America do not have government by the majority. We have government by the majority who participate."  Well, it is your turn to participate.  Tell your Congressional Representative and Senators why they should support PCHETA.  Don't get discouraged that this will take time to pass.  Momentum is building.  Your voice matters.  Wouldn't it be great if Congressional staffers when asked what the top issue constituents were calling about this week could answer PCHETA!  Make it happen.

Promote PCHETA by e-mailing your elected representatives using AAHPM's Legislative Action Center and posting on Facebook and Twitter. 

The Academy's Virtual Lobby Day Participant Guide will help you understand the bill and look up your members of Congress and their social media contact information. It also offers e-mail talking points and sample social media posts, making it quick and easy to request your lawmakers' support.

Please share these details with colleagues and other hospice and palliative care stakeholders, and encourage them to participate in the #PCHETA Virtual Lobby Day!

Need more information or have questions? Email advocacy@aahpm.org

by: Paul Tatum (@doctatum)
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Tuesday, April 19, 2016

When older adults enroll in hospice, symptoms improve

By Alex Smith, @AlexSmithMD

Hospice has taken some tough blows in the last few years. Funding cuts. A reporter at the Washington Post seemingly on a mission to discredit hospice (Washington Post has recently balanced this with some nice reporting, such as this story by Brigham primary care resident Ravi Parikh).

So outside of the headlines and within academia, it’s a relief to see the science falling squarely in favor of hospice in a new study from a well-respected group.

This study, by Shayan Cheraghlo, uses data from the Precipitating Events Project, or PEP study out of Yale, run by Tom Gill. For those of you not familiar with this study, you should be, whether you’re in geriatrics or palliative care. They enrolled 754 community-dwelling non-disabled adults age 70+ and followed them with monthly interviews until death. Enrollment ended in 1999, and only about 100 or so participants are still alive. That is a treasure trove of data about people’s function and symptoms near the end of life. It’s led to several ground breaking papers, including:

  • Disability trajectories in the last year of life. This study found that those with accelerating and catastrophic disability near the end of life were as likely to have organ failure as cancer. 
  • In addition to pain, a wide range of symptoms restrict older adults usual daily activities near the end of life, and increase during the last 5 months of life (first author Sarwat Chaudhry is an awesome physician-researcher). 
  • Breathlessness or dyspnea sufficient to restrict daily activity was present in over half of older adults at some point during the last year of life.


For the present study, published online ahead of print in the American Journal of Medicine, Cheraghlo and colleagues mapped the monthly occurrence of symptoms before and after enrollment in hospice among the 241 PEP participants that enrolled in hospice before death.

This is really where a picture is worth a thousand words. Well, ok, are two pictures worth 500 words each? The top picture shows the prevalence of any symptom that restricts daily activity over time in months, with the dotted line being hospice. The bottom picture shows the average number of symptoms over time.



As you can see, either way you slice the data, restricting symptoms increase sharply in the months before hospice, then decrease after hospice enrollment.

What are these symptoms? Surprisingly it’s not the usual suspects of pain, dyspnea, and constipation, the sort of big three things I would have guessed off the top of my head. The most common symptoms to peak and fall were: fatigue, depression, anxiety, and arm/leg weakness. The authors smarty divided symptoms into how amenable they were to treatment in hospice. It makes the most sense that hospice helped decrease fatigue, depression, and anxiety; explaining reductions in arm/leg weakness by hospice intervention is harder, but not impossible.

Sadly, the mean time from hospice admission to death was only 15 days in this study, mirroring national trends.

How much better might things have been for these older adults had hospice been started earlier? Could that spike in symptoms have been further blunted, or eliminated altogether?
Read more »

Thursday, April 7, 2016

Announcing ePrognosis: Communication - using video to teach prognosis communication



by: Alex Smith, @AlexSmithMD

We're thrilled to announce that our other major project (other than GeriPal, that is) has undergone a radical transformation.  ePrognosis 2.0 is here!

The new site features an easier to use modern interface based on our cancer screening website, now incorporated throughout.

The major new innovation is a whole new section, ePrognosis: Communication.  This section features teaching videos with expert communicators: Sei Lee, Mara Schonberg, and Eric Widera.  The major focus are discussions around prognosis, as viewed through 3 common clinical scenarios: cancer screening, setting diabetes targets, and goals of care/code status for people with a short prognosis.  We have detailed take home teaching points and words to use for key skills, such as how to explain lag time to benefit, addressing uncertainty, and discussing tradeoffs.



Why did we add the ePrognosis: Communication section?  We've heard time and time again from practicing clinicians that they love ePrognosis as a tool.  But the rubber meets the rode in that clinic room and at the bedside - and most practicing clinicians don't know how to talk to patients about prognosis.

Now these videos are not meant to be the be all and end all of how to have prognosis discussions. Is there really such a thing as a perfect communication video?  I doubt it. We wanted to keep the videos short and digestible.  The acting will cause chuckles at times (hey, we were on a budget!)

The main thing to take away from these videos is a discussion.  We've used them to get our trainees talking about how they might do things similarly or differently, to practice, and to out these skills themselves.

Please try out the new site.  Tell us what you think in the comments.  Spread the word!

We are very grateful to the John A Hartford Foundation and the American Federation for Aging Research for their support for the ePrognosis Communication section.

Project leaders for ePrognosis Communication: Alex Smith, Eric Widera, Mara Schoenberg, Sei Lee, Nancy Schoenborn



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Wednesday, April 6, 2016

Is Prevention Possible? Antibiotic Prophylaxis for Recurrent Lower Extremity Cellulitis



Case
As a geriatrician it is not uncommon to have patients present in clinic with signs of infection like cellulitis, an infection of the skin. My patient, who I will call Mr. Sa, is a 79 year old man with a history of hypertension, high cholesterol, and COPD who struggled with recurrent cellulitis of his right lower leg. Despite two prior clinic visits and completed courses of antibiotics, the infection would heal but return several months later.

Clinical Question
In patients with recurrent lower extremity cellulitis, do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate of lower extremity cellulitis?

Best Available Evidence
A search of the literature found a systemic review and meta-analysis of antibiotic prophylaxis for preventing recurrent cellulitis1. The systemic review used the Cochrane Collaboration tool for assessing the risk of bias and the meta-analysis was used to calculate a weighted treatment effect across trials. Five studies met the inclusion criteria resulting in a total of 535 participants with 260 participants taking antibiotics and 275 participants on placebo or not taking any antibiotics. The average age of participants in the five studies ranged from 45 to 67.5 years. A majority of the participants (397) were from the PATCH 1 and 2 studies located in the United Kingdom with a follow up time of 36 months. Statistical methods calculated included risk ratio, Chi2, and I2 tests.

Results
Analysis revealed that prophylactic antibiotics were beneficial for preventing recurrent cellulitis (RR 0.46, 95% CI 0.26-0.79) with a number needed to treat (NNT) of 5 patients. This means that 5 patients would need to receive the prophylactic antibiotics in order to benefit 1 patient (in preventing recurrent cellulitis).

Appraisal
It should be noted that two of the studies (PATCH 1 and 2) were found to be high quality whereas three of the studies were of low or unclear quality with respect to randomization, allocation concealment, blinding, incomplete outcome data, and selective reporting. Overall limitations include a small number of studies performed in the United Kingdom, a heterogeneous study population among subjects, optimal duration of treatment was non-specified, and finally specific antibiotic medication choice (erythromycin or penicillin) varied across the studies. The most commonly reported adverse events with prescribing prophylactic antibiotics were nausea, abdominal pain, and diarrhea. These limitations hinder the generalizability of the study results, especially with varying antibiotic resistances profiles dependent on location.

The review supports the positive impact of antibiotics for prophylaxis against recurrent cellulitis in the United Kingdom. However, there needs to be more randomized controlled trials set in the United States to determine the applicability, specific antibiotic choice, and optimal duration of treatment.

Back to our Patient
For Mr. Sa, prophylactic antibiotics were not prescribed for cellulitis prevention given his allergy to Penicillin antibiotics. However, for future patients who struggle with recurrent cellulitis, the low NNT and low risk of side effects makes prescribing prophylactic antibiotic a treatment to consider.

Reference:
1. Oh, C.C., Ko, H.C.H, et al. (2014). Antibiotic prophylaxis for preventing recurrent cellulitis: A systemic review and meta-analysis. Journal of Infection, 69, 26-34.

By: Megan E. Rau, MD, MPH
@meganerau
Megan is currently a first year fellow in Geriatrics and Palliative Care at Mount Sinai Hospital in New York City.

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, April 1, 2016

Martin Shkreli (aka PalliBro) buys Palliative Care



by: Eric Widera (@ewidera) and Alex Smith (@AlexSmithMD)

In other merger and acquisition news today, palliative care was bought today by former hedge fund manager and current pharmaceutical executive Martin Shkreli (previously known as PharmaBro, now penned PalliBro).

Apparently Mr. Shkreli got the idea for the acquisition from Dr. Atul Gawande.  In his AAHPM/HPNA annual assembly plenary, Dr. Gawande noted that, "Palliative care has amazing outcomes.  If palliative care were a drug owned by the pharmaceutical industry, they would be mass marketing it and making billions."

Sources close to Shkreli state that he carefully pondered how much it could raise the price of this decades old intervention before buying it today. Overnight, the price per dose of palliative care increased by 525 percent, and there are further plans to increase the dose to what the market can bear.

Mr. Shkreli practically gloated about the potential profits in an email he sent out this morning:

“So 5,000 paying bottles of palliative care at the new price is $375,000,000 — almost all of it is profit and I think we will get three years of that or more. This should be a very handsome investment for all of us. Let’s all cross our fingers that the estimates are accurate.”

The pharmaceutical company behind Shkreli’ acquisition released a press statement to reply to potentional concerns of price gauging, stating “we set the drug price to balance patient access to our existing drugs with investment in research and value generation for our shareholders.”
Read more »

GeriPal acquired by Pallimed

by: Alex Smith, @AlexSmithMD, and Eric Widera, @EWidera

We know this will come as a surprise to many of our readers.  We want to make sure that we are clear on the reasons why we at GeriPal have agreed to be bought out by Pallimed:
  1. Pallimed and GeriPal will be better combined than separate.  Think of this dream team lineup of bloggers, all on the court at the same time: Widera, Sinclair, Roseille, Smith, Covinsky.
  2. By being bought out, we can eliminate redundant posts.  Remember when GeriPal and Pallimed both posted about the Temel Study in NEJM showing that palliative care improves quality of life and might prolong life?  Awkward.  We can eliminate this redundancy.  You the readers win by not having to read two posts.
  3. The market is becoming increasingly competitive.  With major new geriatrics and palliative care focused blogs appearing almost daily, it was becoming increasingly hard to compete for scarce readers.
  4. They offered us a lot of money.  "As President of AAHPM, having access to the AAHPM member dues to leverage this purchase really allowed us to make this happen," said Pallimed editor and current AAHPM  President Christian Sinclair.
  5. We've always wanted a green logo.   
  6. Pallimed realized that they couldn't compete in the bigger markets, such as San Francisco.  "It really hit home when the Royals lost to the Giants in the World Series," said Sinclair. "We weren't going to make it as a small market franchise.  We needed to acquire GeriPal to be be able to compete".
We know that there will likely be some changes in store for GeriPal.  We fully expect that some of our contributors will be let go to produce a more efficient blog.

In case we are fired in this consolidation, we want to take this time to thank our readers for their loyalty over the years.  

It's been a great run.

Yours,
Alex Smith and Eric Widera

Same license plate, nicer car...  Thanks Pallimed!

Read more »

Monday, March 21, 2016

Respecting Choices or penalizing them: do DNR orders affect quality ratings?



by: Lena Makaroun, @LenaKMakaroun

Since 2010, the Center for Medicaid and Medicare Services (CMS) has been reporting hospital quality measures for a number of common medical conditions. Intended to provide health care consumers (patients and their families) with information that may guide where they seek care, these measures have undergone multiple iterations in attempts to inch closer and closer to measuring true “quality”. Mortality, a measure as inherently basic as it is complex, has remained a core measure throughout the past decade, and is showing no signs of retreat. With both US hospitals and the patient populations they serve being hugely diverse, efforts to identify factors contributing to mortality statistics independent of the medical care delivered are important and ongoing. In a recent article in JAMA Internal Medicine this past January, Walkey et al. ask a probing question – are hospitals being penalized on mortality quality measures for valuing patient preferences for those who have do-not-resuscitate (DNR) orders? In other words, are hospitals with higher proportions of patients with DNR orders doing worse on mortality quality measures? And if so, should they be?

The authors collected data for one year from 303 California hospitals caring for a total of 90,644 cases of pneumonia (a common disease for which quality measures are collected and reported by CMS). They gathered information on rates of early DNR orders (within 24 hours of hospitalization), mortality rates and co-morbidities among others. When the researchers looked at the association with mortality, they found that while it may have originally looked like a lower percentage of patients being admitted to the lower-DNR rate hospitals were dying, when adjusted for DNR status, this pattern reversed. When separated into patients who had DNR orders and those that did not, patients in both groups admitted to lower-DNR rate hospitals were more likely to die than patients from both groups who were admitted to higher-DNR rate hospitals.

If it seems confusing, that’s because it is. Numbers can be deceiving, and this may in fact be one of the most important take away points from this study. When numbers are being presented to the public to reflect a truth about the “product” they are consuming, the responsibility is on us to make sure those numbers in fact reflect at least some version of the truth. So what is the truth behind these numbers? In short, it’s too soon to say. Another way of presenting the data is that 84% of the patients who died at the lowest DNR rate hospitals were not themselves DNR, compared to only 44% of those dying at the highest DNR rate hospitals. The authors did not find significant differences between the pneumonia related care that patients received or how sick patients were between the two quartiles. If we are to make the value judgment, as we often do in the geriatrics/palliative world of medicine, that dying in the hospital without a DNR order is worse than dying with one, then the high DNR rate quartile hospitals may be being penalized for higher mortality rates while in fact delivering good quality, patient- centered care.

This, however, may be a dangerous conclusion to draw at this point. The descriptive results of this study paint another layer of the picture. When compared to the high DNR rate quartile hospitals, the lowest quartile hospitals served a poorer, more diverse (49% non-white v 22% non-white for the highest quartile) and higher Medicaid insured population. So perhaps the discrepancy we are seeing in rates of DNR status in fact reflect the distinct preferences of a specific patient population based on cultural and socioeconomic factors, rather than the processes of the health systems and hospitals caring for them. While the authors conclude that we should consider adjusting for DNR rates when measuring hospital mortality as a quality measure, there may be danger in this in inadvertently penalizing hospitals that care for poorer, more diverse patient populations. It seems that what we really should be aiming for is incentivizing the process – actually having good, meaningful goals of care discussions, documenting them and then carrying out care that is in line with patient preferences. As our definition of “quality” continues to evolve, we must strive for a definition that involves understanding and respecting patients’ values and preferences.
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Monday, March 14, 2016

Top 25 Studies in Hospice and Palliative Care (#HPMtop25)



by: Kara Bishoff (@kara_bischoff )

Back in 2015 we wrote a post asking for input on what articles should belong on a list of the top 25 articles in hospice and palliative care.   We decided to focus on hospice palliative care studies and trials - as opposed to review articles, consensus statements and opinion pieces.

Here’s what we came up with. It was hard to pick just 25! We highly prioritized clinical utility and tried to achieve diversity & balance. Many others are worthy of inclusion. Take a look and let us know if you have suggested changes for next year.

Module 1: Symptom Management
  1. Randomized, Double-Blind, Placebo-Controlled Trial of Oral Docusate in the Management of Constipation in Hospice Patients. Tarumi Y et al. JPSM, 2013.
  2. Once-Daily Opioids for Chronic Dyspnea: A Dose Increment and Pharmacovigilance Study. Currow DC et al. JPSM, 2011.
  3. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Abernethy AP et al. Lancet, 2010.
  4. Does Feeding Tube Insertion and Its Timing Improve Survival? Teno JM et al. JAGS, 2012.
  5. Parenteral Hydration in Patients With Advanced Cancer: A Multicenter, Double-Blind, Placebo-Controlled Randomized Trial. Bruera E et al. JCO, 2013.
  6. Effect of Duloxetine on Pain, Function, and Quality of Life Among Patients With Chemotherapy-Induced Painful Peripheral Neuropathy: A Randomized Clinical Trial. Lavoie Smith EM et al. JAMA, 2013.
  7. Randomized Double-Blind Trial of Sublingual Atropine vs. Placebo for the Management of Death Rattle. Heisler M. JPSM, 2013.
Module 2: Advance Care Planning
  1. Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers. Steinhauser KE et al. JAMA, 2000
  2. A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA, 1995
  3. Advance Directives and Outcomes
of Surrogate Decision Making before Death. Silveira MJ et al. NEJM, 2010
  4. A Communication Strategy and Brochure for Relatives of Patients Dying in the ICU. Lautrette A et al. NEJM, 2007
  5. Family Satisfaction with Family Conferences about End-of-life Care in the Intensive Care Unit: Increased Proportion of Family Speech is Associated with Increased Satisfaction. McDonagh JR et al. Crit Care Med, 2004
  6. Provision of Spiritual Support to Patients
With Advanced Cancer by Religious Communities and Associations With Medical Care
at the End of Life. Balboni TA et al.  JAMA Intern Med, 2013. 
  7. Family Perspectives on End-of-life Care at Last Place of Care. Teno JM et al. JAMA, 2004.
Module 3: Prognostication
  1. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. Christakis NA et al. BMJ, 2000
  2. Trends in Survival after In-Hospital Cardiac Arrest. Girotra S et al. NEJM, 2012
  3. Functional Status of Elderly Adults before and after Initiation of Dialysis. Tamura MK et al. NEJM, 2009
  4. Patients’ Expectations about Effects of Chemotherapy for Advanced Cancer. Weeks JC et al. NEJM, 2012
  5. “It’s not just what the doctor tells me:” Factors that influence surrogate decision-makers’ perceptions of prognosis. Boyd EA et al. Crit Care Med, 2010.
Module 4: Health Systems & Policy
  1. Cost Savings Associated With US Hospital Palliative Care Consultation Programs. Morrison RS et al. Arch Intern Med, 2008
  2. Hospice Enrollment Saves Money For Medicare And Improves Care Quality Across A Number Of Different Lengths-Of-Stay. Kelley AS et al. Health Affairs, 2013
  3. Do Palliative Consultations Improve Patient Outcomes? Cassarett D et al. J Am Geriatr Soc, 2008. 
  4. Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009. Teno JM et al. JAMA, 2013
  5. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. Temel JS et al. NEJM, 2010
  6. Early Palliative Care in Advanced Lung Cancer: A Qualitative Study. Yoong J. JAMA Intern Med, 2013.

So what do you think we forgot? What studies do you most commonly think about, mention, and cite during your clinical work that's not on this list?



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