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Showing posts from February, 2011

Meeting Our Obligation to Caregivers - the REACH VA Study

I’m tired of innovative health care interventions targeted at those caring for the more than 5 million individuals living with dementia. It’s not that I don’t think they are important. Rather, I find it rather pointless work if these interventions can’t be translated into real world applications. Today, though, the Archives of Internal Medicine is publishing an important study that adapts and implements a multicomponent caregiver intervention into one of the largest health care organizations in the US - the Veterans Health Administration (VHA).

The study, authored by Olivia Nichols and colleagues, translates the Resources for Enhancing Alzheimer's Caregivers Health (REACH II) intervention into the VHA system. The initial REACH II randomized control trial showed significant improvement in caregiver burden, depression, health/self-care, social support, and management of patient behaviors. Caregivers also got something that is worth its weight in gold - one extra hour per day not sp…

Functional Status and Medicare Costs in the Last 6 Months of LIfe

A large proportion of healh care costs is incurred towards the end of life. However, very little is known about how patient characteristics impact of end of life costs.

A recent study in the Annals of Internal Medicine by Dr. Amy Kelley a Geriatrician in the Mount Sinai Department of Geriatrics and Palliative Medicine is a major advance in our understanding of costs of care at the end of life. This study provides the best data yet available about how patient characteristics impact Medicare expenditures in the last 6 months of life. The study examined these costs in decedents in the landmark Health and Retirement Study.

The most important finding of this study is the tremendous importance of functional status as a determinant of end of life medical costs. Kelley showed that both the degree of functional impairment and the slope of functional decline were strong determinants of medical costs. In particular:

Decedents who needed no help with activities of daily living in the last …

Hospice, Palliative Medicine and the MOC

Some years ago, as part of my "Maintenance of Certification" (MOC), I needed to complete a "Self-Evaluation Process". This involved a 'Practice Improvement Module' specifically focused on 'Communication in Primary Care'. The module initially consisted of a patient survey with some 40 questions for my patients to answer either by touch-tone phone or via the internet. These questions were patient oriented and dealt with how satisfied the patients were with various aspects of my practice. This data was presented to me in order to show the forte and foibles of myself and my staff, especially as to how well we interacted and communicated with our patients. Additionally, I completed a 'Quality Improvement Plan' in which I used a practice plan (eg. for a group of hypertensive patients) with a set goal (ie. to improve blood pressure), a measure (ie. blood pressure effect), and an impact assessment (hypertension control). (I chose to use Europ…

Hospice Face-to-Face (FTF) Encounters for Recertification

As of January 1 2011 Medicare has mandated that all Medicare patients receiving hospice care in the home be seen by a doctor or Nurse Practitioner at each recertification period prior to being recertified.

As a case manager for a non profit company providing hospice care in the home my first thought… what an extra burden on the company already stretched financially. Then my thought was, why doesn’t Medicare trust the nurses…. We KNOW if the patient meets criteria or not. So I ignored the idea and waited to see what might happen.

Yesterday just before leaving the house I received a call from a woman who said ”Hi I’m so-and-so I am about to go to your patient’s house for a “face-to-face”. At first I had no idea who she was nor what she was talking about, that expression had not yet become part of my new knowledge. After some back and forth I finally got the picture. This was a Nurse Practitioner about to make a visit for my company in order to keep up with the new mandate.

We met at Mr…

Facing "The Enemy": A new post by Amy Berman

"'Those are my images, aren't they?' I asked the radiologist....The radiologist's response was remarkable. 'Would you like to meet your enemy?' she asked." With these words, Amy Berman of Health AGEnda, a leader in nursing and geriatrics who has recently been diagnosed with Stage IV inflammatory breast cancer, introduces us to one of the unsung heroes of palliative care, the radiologist. You should read her most recent blog post for a moving and thoughtful presentation of palliative care done well, from primary care provider to oncologist to, yes, the radiologist.

As someone who lives with a neuroradiologist, I can attest to the important role these physicians can play in the humane care of people who are learning about their deadly diagnoses for the first time. Particularly in mammography, the radiologist often meets with the patient. At the first patient encounter, the breast imaging expert is frequently placed in the difficult position of knowing…

Pew Internet Report Includes Dementia, Caregiving, Pain, End-of-Life Topics

Earlier this month, Pew released its latest report on what Americans look for online when they are searching for health information. Particularly exciting this time around: their survey included several new topic areas pertaining to geriatrics and palliative care.
In particular, Pew found that:
17% of internet users look online for information about memory loss, dementia, or Alzheimer’s.14% of internet users look online for information about how to manage chronic pain.12% of internet users look online for information about long-term care for an elderly or disabled person.7% of internet users look online for information about end-of-life decisions.
Pew also surveyed respondents as to whether or not they were caregivers, and found that "Caregivers distinguish themselves in this study as people focused on health information. They outpace other internet users when it comes to researching every single health topic included in the survey, often by double-digit margins."
As some of yo…

Future of Geriatric Education is in Peril

The House of Representatives is slated to vote this week on HR-1, a bill that would substantially reduce funding for geriatrics education programs. These include programs that are building the future of geriatrics academic faculty (GACAs) who also happen to be many palliative care junior faculty as well.   It also will severely impact Geriatric Eduction Centers (GECs) and HRSA fellowships (which supports advanced fellowship for dentists, Mental Health Professionals, and physicians).

The H.R.1 bill allocates $352.835 million for Title VII and Title VIII programs (under which GACAs, HRSA fellowships, and GECs are funded), representing a nearly 30% cut in funding ($145.119 million) below FY 2010 funding levels. The 45 funded GECs, as well as the 13 HRSA geriatric fellowship programs and 68 GACAs will be adversely impacted by these cuts to Title VII programs.

If you are in any way interested in protecting the future of geriatrics (and those junior palliative care faculty with GACAs) –…

GeriPal Wins the 'Best Clinical Weblog of 2010'

Medgadget just announced today the winners of the 2010 Medical Weblog Awards. GeriPal came in first for the best clinical weblog!!! Here is the description that was written about our amazing community:

“The Best Clinical Weblog of 2010 is GeriPal, a group blog about geriatrics and palliative care. GeriPal features evidence-based reviews, frequent updates, and the site deploys one of best visual styles we've seen among med blogs. Being a journal that's always open to new qualified authors, GeriPal has developed into a community with a passion and focus on an important topic. We're glad to see that medical blogs like this provide a real and useful resource of knowledge and practical opinion that improves the lives of patients.”
We would like to thank Medgadget for hosting the award and for promoting medical blogging. On the same note, we would like to thank Renal Fellow Network for giving us such a great competition – their site really is amazing and we recommend everyone…

The Clinician's Role in Identifying Loss of Financial Capacity

"Mom's been writing goofy checks..."
"Dad stopped paying his bills...."
"Grandma wired her savings to Nigeria..."

Have you heard these phrases from the family caregivers of your elderly patients?  Have you ever been concerned that your patient may lack capacity for financial decision making?  How do you decide if they lack capacity?  What is the clinician's role in making these decisions?  What is their responsibility?

These important questions are addressed in a terrific new article in JAMA this week by GeriPal co-founder Eric Widera (first author) and contributor Rebecca Sudore (senior author), with co-authors Veronika Steenpass (former UCSF Geriatrics fellow) and Daniel Marson (from UAB).  This is the latest article in the JAMACare of the Aging Patient Series.

The take home points from the article as I see them:
Alzheimer's inevitably leads to loss of financial capacity Loss of financial capacity occurs early in the spectrum of Alzheimer's…

Top 10 Reasons to Go to the Pallimed/GeriPal Party at the AAHPM & HPNA Annual Assembly

Here are the top 10 reasons why you should come to the Annual Pallimed/GeriPal Party hosted during the AAHPM / HPNA Annual Assembly. Before I begin, let me just say that the party was a blast last year. This year, thanks to Christian Sinclair, we have reserved the Showcase Restaurant & Bar in the Marriott Pinnacle Hotel (1122 West Hastings Street) on Thursday, February 17 from 8:00pm to 11:00pm. The party is open to all, so drop on by.

Still not convinced. Here are my top 10 reasons:

You recently read the latest JAMA article about unprofessional behavior by health care professionals on twitter and thought to yourself - "those are my kind of people".You sat through workshops, boot camps, posters, plenaries, case conferences, and SIGs, and not once did someone offer to buy you a beer.You need a break from all that palliative caring and hospicing.You feel a need to dispel the myth that Christian Sinclair is a virtual being who was created by Drew Rosielle after he scann…

Geriatrics Developing Community at AAHPM/HPNA annual assembly

Going to be in Vancouver for the Annual Assembly?

Please come and help develop a Special Interest Group (SIG) in Geriatrics within the AAHPM. The Geriatrics Developing Community will meet Thursday February 17th at 5:15 PM at the Convention Center in Room 211. Network with your GeriPal peers. Your input is needed on what a Geriatrics SIG should be (and your signature is needed too.)




The Geriatrics HPNA SIG meets Saturday February 19th at 7:15-8:15 AM. The Assembly Guide lists all of the HPNA SIG meetings at that time in Room 215-216.

You're Sick. It's Serious.

The American Academy of Hospice and Palliative Medicine has just released a new video called "You're Sick.  It's Serious."



I think it's well done effort to brand palliative care in a constructive manner.  This is the sort of social marketing campaign our field needs to counter that-phrase-that-must-not-be-named.

I wonder how they ultimately chose to go with the animated word design.  What makes palliative care work is really the people, and I guess my only critique would be that this video is strong on message and information content, but doesn't feature the human interaction that is so essential to our work.

They created similar versions about other illnesses, such as dementia, but as far as I can tell they just replace the slide that says "You're Sick.  It's Serious" with "You're Sick.  It's Dementia."

Once you're done viewing the video, go vote for GeriPal for best clinical weblog!  We're neck and neck with the…

Your Patient Stories and JAMA Care of the Aging Patient

The editorial team for the Journal of the American Medical Association series, Care of the Aging Patient: From Evidence to Action invites you to contribute a patient story to inspire a future article. This series is produced by a UCSF Division of Geriatrics editorial team and appears bi-monthly in JAMA. Contributors whose Patient Story is selected for an article will be acknowledged in JAMA and will receive a $500 honorarium. In addition, the editorial team can provide a letter confirming this peer-reviewed contribution.

Click this link to find out more.

Bisphosphonates: The New Fountain of Youth? Or Irrational Exuberance?

Bisphosphonates are a class of medicines that can reduce the risk of fractures in persons with osteoporosis. They are valuable medicines in the right patients. But, over the past week, a number of reports in the media have attributed miraculous life-extending properties to these medicines.

For example, MedConnect (a site that will help you "stay connected to the most important developments in medicine") proclaimed,

"Study Reveals Possible Secret to Long Life - Biophosphonates."

One of America's leading newspaper introduced its story with the headline,

"Osteoporosis medication extends life by five years."

Wow! This must be a really great medicine! Mortality benefits of this magnitude are pretty much unheard of in clinical medicine. The headlines suggest that just increasing use of these common medicines could yield an unprecedented increase in life expectancy marvelling some of the greatest public health interventions of this century.

But the stories are …

Get Out the Vote - GeriPal Style

Football season is now over. Baseball season doesn't start until April. Worst of all, the World Curling Championship is still more than a month away. How the heck are you going to support your ongoing need to cheer on the home team? Here is a suggestion – root for Geripal in Medgadgest's Seventh Annual Medical Weblog Awards.

Geripal has been nominated as one of the 5 Best Clinical Sciences Weblogs. The competition is fierce with names like Academic Life in Emergency Medicine, EMCrit blog, Renal Fellow Network, and Resus M.E! Even though I really like all their sites, I think it is time to show them what a community focused on geriatrics, hospice, and palliative care can do when we put our minds to it.

So, lets get out the vote. Click on the award link and take 3 seconds to vote for geripal (really - I swear - all it takes is 3 seconds).

by: Eric Widera

Vote for GeriPal for Best Clinical Sciences Blog (Polls close Feb 13, 2011)

Hospital DNR Orders - WTF (Why They Failed)

A thought provoking article just came out ahead of print in the Journal of General Internal Medicine. It is titled "Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them" and authored by Jackie Yuen, Carrington Reid, and Michael D. Fetters (a quick disclosure – I'm unbelievably excited that Jackie is coming to our UCSF Geriatrics Fellowship next year – we need more bright minds like her in our field). The paper lays out four main failures of DNR orders and four possible solutions.

Let's start with the least controversial part of the paper - the four failures of DNR orders. To sum it up – discussions rarely occur, and when they do occur it happens much too late with doctors not really giving enough information for patients to make a true informed decision. Worst of all, physicians make unfounded assumptions based on the presence of a DNR order that may limit other treatments (please see my rant on AND orders for issues around extrapolat…