Friday, December 6, 2013

Getting better with age

Being a geriatrician, I am eternally optimistic about aging.  Therefore I love this article on coaches in the NFL.
The Cardinals' Secret: Elderly Coaches!!

Go Cardinals!

Friday, November 22, 2013

How to think like a geriatrician

So hopefully (optimism), I'll write a series of articles about how to think like a geriatrician.  Geriatricians deal with a specific patient population that is unique-but not just because the patient is old.  Age is just a number (seriously).  But there are other things that go along with aging.  This graph/powerpoint of how I think about things.  All of us, whether we like it or not, are moving from the left side to the right side.  Exercise, living right can delay that.  But eventually, as long as we are not hit by a car, will make it to the right side.  The purpose of this picture is to show how the practice and application of medicine fundamentally changes as one becomes more frail and as goals change to being more palliative.  Medicine becomes more collaborative, more of an art.  Standard medicine begins to fail.  The picture shows why that may be.

Thursday, November 21, 2013

Generic drugs are good! Don't listen to drug companies

I enjoyed reading this.  It's always amazing to me how many people think that if they care about their health they need to get a brand name drug.  It's scary how effective drug companies are at marketing and how much people are willing to listen to drug companies.

Friday, November 15, 2013

An ICD: A $30,000 mistake that shows what's wrong with health care

So I previously wrote about a patient of mine who got an Implantable cardioverter-defibrillator (ICD).  To recap, he was a 92 year old gentleman, with metastatic melanoma (choosing not to pursue chemotherapy), Class 3, Stage D heart failure (end stage CHF) and worsening frailty with a fall and minor hip fracture (no surgery required).  When he was in the hospital for a CHF exacerbation, his ejection fraction was found to be less than 30%.  When someone's ejection fraction is less than 30%, they are at increased risk for sudden cardiac death and insurance will cover the cost of an implantable defibrillator (ICD).

In my previous post, I discussed the utility of an ICD for this patient.  To summarize, his cardiologist had visited him in the hospital (for a CHF exacerbation) and told him an ICD would "help his heart."  The patient understood this to mean that it would help his heart pump and he would feel better.  The doctor meant it would help restart his heart were he to die of an arrhythmia (which was not something the patient was trying to avoid).  When I saw the patient, his wife and daughter, listened to their goals and explained this to them, they realized it was a mistake and they wanted it shut off.  The patient actually wanted to sign on to hospice, prioritize having a peaceful death and feeling as good as possible.  None of these could be accomplished by an ICD.  In fact, an ICD would be an obstacle.

Geriatricians (apparently), are known for complaining about the health system, and well, yes, I am going to do that.  So what did this "oops" cost?

Well the hospital gets a fee of $26,000-30,000 for the 10 year device.  Some of that is profit.  Some goes to the device manufacturer.  The consulting cardiologist gets paid a fee of about $100.  The cardiologist inserting the device gets paid a fee of about $1,500.  I get paid $80 for having a 45 minute conversation with the patient, wife and daughter, to explain the risks and benefits, discuss goals and help come to a shared decision about the appropriateness of an ICD.

Again, I get paid $80, everyone else gets >$30,000.  For the "oops," everyone keeps their money and profit  No one has to pay anything back to Medicare. The hospital, the device company and the proceduralist make out like bandits.

Reimbursement needs to change in order to achieve good quality care for patients and minimize waste.

Specialists who do procedures get paid too much (yes I said it) and need to be held accountable for wasting resources.

Somehow I (and geriatricians in general) need to get credit/paid for helping patients achieve their goals through appropriate medical interventions and saving money while doing so. What would have happened if I had met with the patient before the placement of the ICD so that when the cardiologist suggested it, he said no?  The hospital would have lost money, the cardiologist, the proceduralist and the device company would have lost thousands.  Medicare would have saved >$30,000 but none of that would have been credited to me or even recognized that I had a role.  Everyone gets paid thousands for a 2 second statement "this will help your heart," but I get paid $80 for a 45 minute discussion.  In other words, guiding the medical care that a patient gets, to make sure it is appropriate, does not get reimbursed.  Saving money (not that that is necessarily the main goal but it's not a bad secondary goal), is also not reimbursed.  Doing more, risking more, spending more gets reimbursed tens of thousands.  This is why sometimes older adults feel like they are on an express train of medical care that they can't exit.

Good communication should be reimbursed.  It leads to better care.  It is a skill just like putting in an ICD or consulting on a patient or making a device.  I would argue that for this patient, the key skill he needed was communication.

What is wrong with health care in the United States is how medical care gets reimbursed.  They system is geared to providing inappropriate, useless care.  And nothing being proposed in Washington is changing this disaster.

Saturday, November 9, 2013

When to stop statins in the elderly

One of the challenges for me in blogging (occasionally) is that I tend to think about patients that I have just seen but due to privacy, I definitely do not want to reveal any identifying information.

One of the concepts that geriatricians get easily and intuitively is that not all medications are meant to be life long for a variety of reasons.  But that concept seems to be missed on many non geriatricians.  The following case demonstrates this point.

Recently I saw an elderly gentleman with dementia (elderly means late 80s to 90s).  He was not complicated medically. Pretty typical health issues including high blood pressure and high cholesterol.  But his major current issues was quite a sudden decline in memory, ability to care for self and weight loss.  These signs, taken together, along with his advanced age and no obvious easily reversible cause discovered leads to a very poor prognosis.  Family understood this and was asking about hospice.  The patient had a good quality of life, was comfortable and not in pain, but the family clearly wanted the goals of his care shifted to function, quality of life, maintaining independence and community at home.

When someone has an acute deterioration of their function, I cast a very wide net as to what is causing deterioration.  There's a lot that goes into that evaluation, but as a geriatrician, I always look at medications to see if a patient is taking a medication that is harmful or unnecessary.  Statins do cause side effects and they are often a medication that is potentially harmful and unnecessary (especially over short periods of time).  So for this patient, since there was no readily obvious cause of the sudden deterioration of memory, function and weight, it is worth trying to stop the statin to see if it is a culprit.  Several weeks later when I saw the patient back, I found out that the primary care doctor was too nervous to stop a statin because the man had a heart attack or stroke years (decades?) ago.

I get so used to stopping/holding/reducing meds in the face of side effects/unstable patients that I am always surprised (but shouldn't be) when another physician is too afraid to stop a medication despite staring at a symptom that well could be a side effect of the medication.

Reasons to start a statin are fairly clear: LDL higher than a certain level (100, 130 or 160) or someone who has had a heart attack, stroke or has diabetes.

But what are good, concrete reasons to stop a statin?  Well, there are no good published guidelines.  So here goes.  I'll write one!

First let me review what statins do and how they do what they do
1.  Statins prevent heart attacks in older adults.  While they prevent strokes and heart attacks in younger adults, in older adults that has not been shown to be the case.
2.  Therefore, statins are preventative medications.  They do not confer any immediate functional, comfort, therapeutic (fixing) benefit to the patient.
3.  The longer you take a statin the more effective they are.  So while a statin may help 1 in 45 patients taking a statin to prevent a heart attack over 2-3 years, over 15 years it may help 1 in 10 patients (a better ratio).  Statins are much more effective over decades.  Statins confer no benefit over months (unless you just had a heart attack or stroke).
4.  Statins can cause weakness, muscle ache, mild hepatitis as common side effects.  And they interact with other drugs.

So why stop statins? (not in any particular order)
1.  They are causing side effects.  General principle of life is that if a treatment is causing a side effect, then it isn't worth it.  Even in high risk patients, statins only benefit 1 in 10 patients over 15 years.  Most people don't benefit from these medications.  Taking a medication that is non beneficial and causing a side effect is the worst of both worlds.  Even for that 1 in 10 that may benefit over 15 years, I would argue that tolerating a side effect that long still might not be worth it.

2.  Prevention of heart attacks and strokes no longer matters.  This is true for people who are at the end of their life.  Keeping their LDL less than 100 is an abstract goal that does not matter any more.  This reason is true of almost everyone on hospice.  Sometimes treating medical problems that cause symptoms (COPD, CHF) is more important that treating medical problems that do not cause symptoms (like high cholesterol).  Prevention just stops being a priority because the symptoms that a person actively has is more important than an event that could theoretically happen.

3.  Other goals (like comfort, function, independence, quality of life) are way more important, higher priority, need more attention, are worth the energy etc.  You get my point.  It is amazing to me how doctors prioritize problems that don't match a patients priorities.  This is the flipside to point #2.  Sometimes goals just are not achieved by fixing a number on a blood test.  Statins never make anyone more comfortable and never increase function.  Most are achieved by methods not involving medications.  One of my pet peeves is that each specialist views their organ system as the most important organ system.  Doctors are not very good at prioritizing competing medical problems.

4.  Life expectancy is short.  Let me just say this-Statins do nothing over a timeframes of less than a year.  Statins work over years to decades.  Stopping a statin for the last 6 months of a person's life will not cause them to have a heart attack or stroke.  If they have a heart attack or stroke, they would have had one anyway.  No one NEEDS to die with a statin.  In fact, if someone does die of a chronic illness taking a statin up to the moment they died, I would argue that the physician was not appropriately tailoring the medications for the situation.

5.  2% is seen as a small meaningless number.  So over 2-4 years, in a general population of 100 older at-risk adults taking a statin, 2% will have a heart attack prevented.  This is a quantitative way of looking at the question.  The other would be, taking tons of pills is a big pain in the neck, or a person just isn't sold that a 2% reduction is enough to take a daily medication for 2-4 years (365 doses x 4=1460 pills!!!).  Now physicians are wired/taught/mandated/reimbursed/pressured into making every health issue seem like a BIG DEAL, but the dirty reality is whether someone takes a statin or not (over short time frames) will not likely affect their health (for better or for worse).  For my patients, whether to take something is a collaborative discussion.  Patients do get to have a say in these type of decisions. Guidelines be darned.  After all, patients ultimately have to live with the consequences.  Effectiveness is in the eye of the beholder.

6.  Lastly, it never hurts to take a break.  This isn't a reason more than it is just a plain truth (from my perspective).  Yes, for those who just had a stroke or a heart attack, there is an increase risk for another event if a statin is discontinued in the first year.  But for long term patients, stopping a statin for a short period of time (4-6 weeks) is perfectly safe (  Yes, after months and more likely years of not taking statins, there will be differences in heart attack and stroke rates (maybe strokes) but it will be minimal.

So there you have it, my reasons for stopping statins.  There are logical, concrete reasons that a person should stop taking their statin based off of ideas such as avoiding side effects, reduced efficacy, goal directed medicine and life expectancy.

Sunday, October 13, 2013

CPR outcomes-how do I decide my code status?

So I finally got around to my literature review on CPR outcomes in older adults.  Cardiopulmonary resuscitation status (or code status) is asked at every hospital admission as required by law.  But how does one make a decision regarding whether or not CPR is right for them?  Understanding CPR outcomes is a starting point.  Having an accurate understanding is the anchor for deciding fit between values and the procedure (in this case CPR).

In a nutshell:
1.  CPR achieves

  • Nothing for 50% of patients in the hospital
  • For around 35%, the patient has a prolonged death in the hospital
  • For around 15% the patient survives to leave the hospital.
  • About 8% leave the hospital about the same as when they came into the hospital.

            For those with end stage anything disease (end stage heart failure, COPD, renal disease on dialysis, severe dementia, metastatic cancer), survival rate are easily less than half of that (so 7.5% survive and 4% survive to be about the same).  Because of the way these studies are done, the number could be cut in half again.

So for sick patients, older patients, the best number to use would likely be

  • About 1-3% with severe disease will leave the hospital about the same as when they came in.

2.  There are risks.
  • Trauma.  1/3 break ribs for example.  More as you get past 70 years old.  CPR can hurt.
  • Prolonged death that is more painful.  Some people, instead of suddenly dying peacefully in their sleep from their heart stopping, will die from not being able to breath on a mechanical ventilator.  (about 35% of those who get CPR).  
  • Living more dependently.  About half of survivors who were at home need to go to a Nursing home after CPR.  
  • If a person is full code, then by definition, CPR will be the last thing they experience on this earth.  

So what to make of all this?  Everything is in the eye of the beholder.  For some people, having a 2-3% chance of living longer (even if it is just a couple of months) is totally worth it.  For others, it seems like a vanishingly small percentage and a complete waste.  There is no right answer.  For others, the trauma, risk of prolonged death, or the absence of a peaceful death is something worth avoiding at any cost.  For others, it is no big deal.  

So this is how I think about it:
CPR is good for you if ALL of the following are true:
  1. Longevity is still an important goal
  2. Dying peacefully is not a goal
  3. Avoiding a prolonged death is not a goal
  4. Comfort is not an important goal
  5. You have a high tolerance for trauma
  6. You're okay with living very dependently in things like bathing, dressing, toileting and feeding.
  7. You are a gambler/risk taker.  Although you're hoping that after CPR you'll be the same, you won't regret your decision if you end up with a feeding tube for example because you're happy you went for it.  
If one of the above is not true, well then you have a decision to make right?  Is the tiny chance to living longer worth the pain?  No one wants pain but is the chance worth it?  Not to be too glib, but to quote Clint Eastwood, "you've got to ask yourself one question: 'Do I feel lucky?' Well, do ya, punk?"  There's a certain amount of gambling optimism to be full code.  Or absolute fear of dying where you're willing to take risks.  The chances of coming through is a little better than playing the pick 3 lotto.  So if you're really ticked off every time you don't win after playing the pick 3 lotto, well, then, you'd probably not be too happy after you get CPR. 

Onwards:  CPR is not a good choice for you if any one of the following is really important for you
  1. Longevity is no longer a goal at all
  2. Dying peacefully is very important (i.e. without painful procedures, with family present)
  3. Comfort is a non negotiable goal
  4. Avoiding a prolonged death is vitally important
  5. Living very impaired is to be avoided if possible 
  6. You have no desire to put up with any more pain
  7. You're not a gambler.  
Anyway, it is up to the patient and physician to work together to figure out the fit between a patient's goals/values/limits and what CPR can realistically achieve for that patient.  It is much more complicated than "I'd like to live longer so let's go for it."  CPR is likely to make a person worse (all good intentions aside) and I would not want a person to be surprised or regret it.  

Wednesday, July 10, 2013

CPR outcomes

Long time between posts.  This article is heading in a direction that I like which is making outcomes of CPR transparent.  More to follow.

Monday, February 18, 2013

Another goals of care sheet

I am always looking to find a perfect form that would help me understand and help patients clarify their goals of care.  There are so many different values to discuss such as
Longevity goals
Quality of life goals  (both ideal and minimal)
Function goals (both ideal and minimal)
Comfort goals
Risk tolerance
Pain tolerance
Definition/purpose of suffering
Emotional issues
Cultural issues
Ideal place of death
Worries of abandonment vs desire for community
Views on technology (fear vs embrace)
Role with family (involved, independent)
Role with doctor (involved, independent)
          Model of decision making (informed consent vs paternalistic vs collaborative)
Concerns of being a burden to others (physically, emotionally)
Milestones to live for (an upcoming wedding/graduation/birth)
Dignity issues (care received, relationships, function)

There are a ton of medical decisions and implications that need to be made as well.   
Current health status
Projected health status/anticipated quality of life
Burden of medical interventions (both pain and risk)
In addition to a million individual decisions (Dialysis, ICU care, ER care, invasive testing, CPR etc)

I've made sheets of my own, but one that I am finding very very interesting is "The Conversation project."  I'm thinking of abandoning my own forms and using this one paired with a POLST form.  I'll let y'all know how it works out!