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Showing posts from July, 2009

Family Caregivers: The Silent Long Term Care System

Long term care is a hot topic. When people talk about long term care, they are generally talking about nursing homes. Policy makers put a lot of attention on nursing homes because they cost so much money. About half of nursing home care is paid out of public dollars. In California, in the setting of our state budget fiasco, the high cost of nursing home care to the state has gotten a lot of attention. But we often forget that there is another long term care "system": Family caregivers. It is important to recognize that for every person currently in a nursing home, there is at least one more person still living at home who is disabled enough to live in a nursing home. They live at home because of the great efforts provided by their caregivers. Family caregivers are the unsung heroes of the US health system. They often provide care at great personal and economic cost. Many give up their jobs so that they can care for a loved one. But caregiving can be very hard--often harde

Gawande, Greed, and You Eat What you Kill

Much has been made of Atul Gawande's New Yorker article investigating the root causes of high healthcare costs in McAllen Texas. President Obama made the Gawande article required reading for White House staff. In the blogging community, some of my favorite commentary has come from our own Eric Widera here , the Buckeye Surgeon here (with a response from Atul Gawande here ), Wachter's world here , and the Director of the Office of Management and Budget Peter Orzag (!) on his white house blog here . I developed the idea for this post as a comment on KevinMD's site here (second highest rated health blog on wikio ; see the lively discussion in the comments). Atul Gawande delivered a follow up to his article as a commencement speech to the University of Chicago Medical School, here . The fine research from Dartmouth cataloging the dramatic variation in Medicare Expenditures has been well publicized for some time. High cost areas do not deliver higher quality care for

Pharmaceutical Industry Influence on Guidelines and Performance Measures

The effect that industry influence has on individual doctors, hospitals and clinics through free lunches, CME dinners and trips and getting on the formulary has been well documented. However, one area that has not received enough attention is how industry encourages more care by financing and supporting more aggressive clinical guidelines and performance measures. More care is sometimes beneficial for patients and sometimes harmful; however more care is almost always beneficial for industry. I'll highlight 2 instances. Amgen and KDOQI (Kidney and Dialysis Outcomes Quality Initiative) Amgen "is the founding and principal sponsor" of KDOQI, getting their name and logo as a supporter of guideline development. KDOQI has established anemia guidelines on what is appropriate targets for hemoglobin in dialysis patients. These guidelines have led to a steady increase in average hemoglobin values in the US dialysis population from 10 in 1993 to 12 in 2004. The primary treatment

Hospice care of the Geriatric patient

I am new to blogging, actually this is my first attempt and I write with trepidation. So, thank you, Alex, for the encouragement and wriggle room to write with imperfection. Like yours, my academic and clinical background is in both geriatrics and palliative care. Prior to my work as a nurse practitioner in an inpatient in hospice and palliative care unit, I worked for eight years as a hospice case manager in the community. I work integrally with the outpatient hospice community and I am worried. I am worried about the care of the elderly in hospice. I am worried because I know so much more than I did as a hospice RN. I know more about the pathophysiology of end stage diseases, how tricky it is to balance appropriate medication management of elders with multiple co-morbidities, what medications to use and what to avoid in the elderly. I look back on all my years as an RN advising, recommending, and instructing home care patients about medications I didn’t know enough about. I wonder h

Survival after in-hospital CPR in the Elderly

NEJM published a paper last week looking at CPR outcomes in the elderly . The main question of the paper addresses whether the rate of survival after in-hospital cardiopulmonary resuscitation (CPR) has improved from 1992 through 2005, and whether there are any patient characteristics that predict survival. The basic results showed that 18% of Medicare beneficiaries who underwent CPR in U.S. hospitals survived to discharge. There was also no increase in the rate of survival from 1992 through 2005, and predictors of poor prognosis included male gender, age, race, multiple coexisting illnesses, or patients admitted from skilled-nursing facilities. In addition to its primary aim in addressing the temporal trends in survival, this paper adds to the literature out there on the short term outcomes of CPR. This outcome data is vital to have when discussing the role of CPR with patients. This paper though does not attempt to answer all the questions that arise when having these discussion

Attracting Readers and Gaining Momentum

As our blog is new, and Eric and I are completely new to blogging, I recently asked an old friend and active and successful blogger for advice about blogging. Specifically, I was interested in how to grow our blogging readership. His thoughtful reply can be found as a blog post on his site, the baseline scenario . His post, and those in the comments, contain useful links to other bloggers' advice about how to start blogging, such as this post by Felix Salmon , and this post by problogger on how to optimize search engine hits. Take home points for me about our site are as follows: 1. We need to post more often, not worry about quality as much. 2. We need to link to other bloggers, comment on other bloggers sites. 3. Felix Salmon says it takes about a year for your blog to gain momentum, so we have time. 4. We should eventually post about every new and exciting policy or newsworthy article in the literature. 5. We need to be less journalistic/perfectionist and less afraid of pu

Medicine as a business

Although this is not specific to geriatrics or palliative care, this is an eloquent article that raises the real-life health care (perhaps more appropriate to say 'economic') environment that we now practice in. We may enter and even graduate from medical school with altruistic qualities of caring for the patient, the whole patient, and family (and never think about money). Certainly those of us entering geriatrics and palliative care lean farther toward this direction as evidenced by the fact that most geriatric specialists are paid less than internists who don't have the additional training. This article strikes me as particularly poignant as the last 2 years of my post-training 'career' have been filled with countless examples of how the dollar impacts the day to day care I (and other physicians) provide. Here are just a few examples: - Every month since the start of 2009, the low-income commu

American Geriatrics Society and the AMA: Time to Part Ways?

There is very eloquent letter from Richard Stefanacci and colleagues in the June edition of the Journal of the American Geriatrics Society about the relationship between the AMA and the AGS. (Stefanacci RG; Wasserman MR; Beers MH. Moving Beyond the American Medical Association. JAGS;2009:1117-1118). The context is as follows. The AMA sponsors the resouce-based relative value scale updates committee (RUC). This very obscure sounding body is VERY important. It advises CMS on updates to the system that determines how physicians will be paid for their services. This is the system that ultimately results in much greater payments for procedural care than for services based primarily on talking to or examining patients. The reason the RUC is so important is that CMS accepts the vast majority of its recommendations. One way of looking at this: The CMS essentially relies on the AMA (via the RUC) to determine the relative value of physician services. The current approach to payment for these s