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Limited function, high costs, and the need for a better approach

dodson%20headshotA recent article in the New York Times described the “High Price of Failing America’s Costliest Patients.” The author highlights the disproportionate healthcare costs incurred by a small percentage of patients in the U.S. (for example, 5% of the population accounts for 50% of the costs). These costs are not simply attributable to traditional disease entities that we learn in medical school – for example, patients with a chronic illness plus functional limitation (inability to care for themselves or perform routine daily tasks) have four times higher medical costs, according to the Commonwealth Fund. With an aging U.S. population, these functional limitations, which complicate already difficult management decisions in patients with chronic illnesses, are going to become more common in clinical practice over the coming decades.

We clearly need better models of care for functionally limited, complex older patients including those with cardiovascular disease. The Times article highlights several models already underway – including a Medicare Advantage Plan which spends more upfront time on team-based care (including physicians, nurse practitioners, and social workers) to achieve the aim of reduced downstream costs. These models are most likely to be successful if they focus on the “whole patient” rather than a single disease. For example, hospital readmissions in older patients (which are a major driver of healthcare costs) are usually for something other than the index condition, including in patients with heart failure (where fewer than half of 30-day readmissions are for heart failure). Efforts focused on a single disease entity (for example, diuretic management for heart failure) therefore may miss the larger picture. Another innovative approach to management involves incorporating patient goals into care plans, which moves beyond traditional disease-based management, and may be especially relevant in the setting of functional limitations. Ongoing work by Mary Tinetti, Caroline Blaum, and others is helping to incorporate goal elicitation, and alignment of treatment plans with these goals, into routine clinical care.

In my opinion there’s unlikely to be a “one size fits all” approach that solves the challenge of improving care in older patients with functional limitations. However I think the general principle of working beyond our silos, both by participating in teams with other clinicians and by directly eliciting goals from patients, will make a difference.

 

By: John Dodson, MD, MPH

A Healthy Old Age

karen-alexanderMaintaining a healthy lifestyle in our 30s, 40s or 50s is an important determinant of how we will age. New information confirms this association between lifestyle and healthy aging has no expiration date. Healthier lifestyles in our 70s and beyond continue to yield benefits as demonstrated by the Three Cities Study. In 2010, the American Heart Association released Life’s Simple 7, which is a 7-step list of ideal lifestyle modification goals that target improved cardiovascular health. AHA Life’s Simple 7 are a mix of behavioral (healthy diet, nonsmoking, moderate to vigorous physical activity more than 150 min/week) and biological (total cholesterol <200 mg/dl, blood pressure <120/80 mm Hg, fasting glucose <100 mg/dl, and body mass index <25 kg/m2) targets, with each goal having levels of ideal, intermediate, and poor attainment. Attainment of Life’s Simple 7 goals is associated with better cardiovascular health, better general health, less cancer, depression, cognitive impairment, diabetes, frailty, and all-cause mortality.

Better attainment of the American Heart Association’s Life’s Simple 7 goals among 9,294 men and women from France (mean age of 73.8 years) was associated with better health outcomes a decade later. Older adults who met at least 5 of 7 ideal goals at baseline had a 35% lower risk of all-cause mortality. Adults who met 3 to 5 ideal goals (intermediate health) had a 17% lower risk of all-cause mortality. Even better news is that outcomes improved with each goal attained; even intermediate goal attainment had a beneficial association with outcomes. Now for the bad (if predictable) news: only 1 participant met all 7 goals at ideal status, 5% met at least 5 of 7, and 15% met all behavioral goals. This attainment is comparable to similarly low rates in much younger populations around the US and world. Even though aging biology impacts non-attainment of ideal status on some measures (e.g. blood pressure and cholesterol), healthier behaviors were more likely among longer lived adults. Since healthy behaviors may prevent cognitive impairment and frailty, better goal attainment in older populations is important for optimizing survival and quality of life, while limiting time spent with illness and disability. This article has emboldened me to push my older patients to continue to shoot for Life’s Simple 7, giving few a “pass” based solely on age. Even more relevant for the older population, working to achieve these goals is likely to yield benefits before attaining ideal status. A favorite Tibetan proverb applies to those age 70 and beyond: “The secret to living well and longer is to eat half, walk double, laugh triple, and love without measure.”

 

By: Karen Alexander, MD

Time for Action: Including Older Adults in Clinical Trials

dodson%20headshotWe recently published an editorial in the Journal of the American Geriatrics Society entitled “Time for a New Approach to Studying Older People with Ischemic Heart Disease”. This was in response to a research article by Bourgeois et al. demonstrating that of medication trials for patients with ischemic heart disease published between 2006 and 2016, over half (53%) excluded older adults. The authors’ findings underscore the continued problem of under-representation of older adults in the most rigorously conducted research studies, which makes translating these studies’ results into practice especially challenging.

This is a longstanding problem that was highlighted by the FDA over 25 years ago. In our editorial, we highlighted several potential next steps to address this issue:

  1. Design clinical research studies with no upper age limit. Alternatively, mandate an explicit lower age limit for inclusion – for example, only enroll patients age ≥75. Since there are fundamental phenotypic differences in older patients (including aging-related impairments such as frailty, sarcopenia, visual/sensory impairments, and cognitive impairment), this approach would ensure these characteristics are adequately represented.
  2. Create an Office of Geriatric Health and Aging within FDA, which would provide expertise for review of protocols on dosing, enrollment, and data collection in older patients.
  3. Add an exclusivity rule to extend patent life in drugs with proven safety and efficacy specifically in older adults, which would incentivize drug manufacturers to focus on aging. This approach has been previously described by Skolnick and Alexander.

These are just few examples of concrete steps that can be taken to address a problem that has long been recognized. With our aging population, and in light of current clinical uncertainties in cardiovascular medicine, there is a critical need for action.

 

By: John Dodson, MD

The Emerging Field of Palliative Nephrology

Jen Schere“To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks real advance in science.”

-Albert Einstein

Mrs. RS is an 83 year old female with coronary artery disease, congestive heart failure (EF=30%), and chronic kidney disease stage IV-V. She was referred to my kidney palliative care outpatient clinical program named Kidney CARES (Comprehensive Advance kidney disease and End stage kidney disease Support) to manage her kidney disease. She lives on her own and walks with a cane. Unfortunately, she had two recent admissions to the hospital for heart failure. With each admission, her kidney disease has worsened, as has her functional status. Mrs. RS is cognitively intact and willing to take an active role in her care. On her first visit, she reports living with constant arthritic pain and anxiety about her disease burden. She shares with me that maintaining her independence is her current most important life goal. She would never want to use machines to keep her alive.

As a geriatric patient living with both heart and kidney disease, Mrs. RS is a common referral to a nephrologist. The prevalence of cardiovascular disease (CVD) in older patients with CKD is nearly twice that of those without CKD (68.8% versus 34.1%). Additionally, co-diagnosis of CKD and CVD worsens survival prognosis. Clinically, Mrs. RS represents many patients I have seen throughout my seven years of practice as an attending nephrologist. However, now I was meeting Mrs. RS after completing a palliative care fellowship and a shared clinical focus of both specialties.

Palliative care is specialized medical care delivered by an interdisciplinary team, that focuses on quality of life and living well with serious illness. Specific skills of palliative care include physical and emotional symptom management, spiritual support, assistance with shared-decision making, and facilitation of advance care planning. It can be delivered while a patient is pursing curative care. Palliative care has gained importance in current health care policy given the transition to patient-centered care that is called for in the Affordable Care Act.

How can palliative care be integrated into the care of Mrs. RS? This starts with identification of her goals. Mrs. RS would like to live the remainder of her life at home, independent, and symptom free if possible. Although these are relatively simple, the unfortunate reality of current practice is that the goals of patients are often not met in clinical care plans. Rather than a person-centered discussion in the context of their individual prognosis, a CKD stage V patient is commonly faced with disease focused discussions of dialysis initiation, the level of phosphorous and potassium in their diets, and fluid status. For Mrs. RS, best practice calls for a discussion that asks the following questions: What does she understand about her illness? What does she expect in the future? What brings her life joy? How can we support her family throughout her illness? Is dialysis the right choice for her? What is most important to her now that she understands her prognosis? How can we treat her symptoms?

This patient centered approach to care does not detract from disease focused treatment, but rather enhances the existing paradigm. For example, randomized controlled trials for patients with lung cancer have shown that integrated palliative care, delivered alongside standard oncology care and introduced early in the treatment process significantly improves the quality of life of patients, while also extending survival. Unfortunately, we have no comparable data for patients in the U.S. living with kidney disease. There is observational data from the United Kingdom and Australia suggesting that conservative management (non-dialysis) and integrated palliative care can improve quality of life. Importantly, some evidence suggests that for older adults living with heart disease, dialysis initiation does not necessarily lead to a survival advantage. It is time to ask these questions to similar patients living in the US.

To our knowledge, Kidney CARES is the only outpatient interdisciplinary kidney palliative care program in the U.S. It is modeled after a similar care delivery model in Australia. We hope that rigorous study of the implementation and clinical outcomes of our care delivery model can answer questions that directly impact the care of patients similar to Mrs. RS. It is her story that illustrates the value of new approaches to care, one that puts the patients’ goals at the center.

 

By: Jennifer Scherer, MD

Patient-directed Advance Care Planning

dodson%20headshotSeveral weeks ago, the American Geriatrics Society (AGS) held its annual scientific sessions in San Antonio, TX. This meeting attracts geriatricians and other professionals dedicated to caring for older adults. As a geriatric cardiologist I attend AGS regularly, and in recent years I have seen interest from other subspecialists continue to grow.

One of the most interesting abstracts presented at AGS this year was by Dr. Rebecca Sudore (UCSF), who discussed a randomized clinical trial aimed at improving advance care planning (ACP). Essentially, Dr. Sudore and colleagues created an interactive, patient-centered advance care planning website. They then assigned half of participants to review this website, and the other half to receive usual care. After 9 months, documentation of ACP improved significantly in the group assigned to the website. They published these findings concurrently in JAMA Internal Medicine.

One of the true innovations of this study is that they targeted patients without requiring intervention on part of the clinical team or health system. This helped to overcome some of the barriers we face in our busy practices with regards to ACP; we all know it’s important, but are often busy with more acute medical issues and long-term planning is therefore overlooked. I am interested in seeing whether Dr. Sudore’s work can be scaled to other healthcare settings in the coming years.

 

By: John Dodson, MD

Cardiologist Confessions: My Journey to Patient Priorities Care

masoudi-frederick-2011 v2For a cardiologist, my interaction with geriatric medicine occurred relatively early in my career. I was an aspiring academic preparing a career development award. I had the good fortune of being involved in a national project sponsored by the Health Care Financing Administration (HCFA, now the Centers for Medicare and Medicaid Services or CMS) to assess the quality of care for Medicare beneficiaries hospitalized with heart failure called the National Heart Care Project. I had settled on what I thought was an important line of research—the epidemiology and outcomes of older persons with heart failure and preserved systolic function. I felt that I had everything I would need for a compelling application to the NIH—an interesting project, excellent career and scientific mentors, and a coherent research plan.

Fortunately, I took the advice of mentors and peers to contact the program officer at the National Heart Lung and Blood Institute (NHLBI), to which I planned to submit my grant. The NHLBI seemed like a natural fit for a cardiologist. At the time, though, cardiovascular outcomes research did not exist as a field, and the program officer at the NHLBI told me frankly that my application stood little chance because of the topic. I was profoundly disappointed, but should have been grateful for her honesty.  It occurred to me that the National Institute on Aging (NIA) might be interested. When I called the program officer there—Andre Premen was his name—the reception could not have been more enthusiastic. While a physiologist, he exuded interest in the topic and strongly encouraged me to apply. I was funded on the first submission (one for the “better lucky than good” file). Thanks to the NIA, my academic career was launched.

My early research with the Medicare data from the National Heart Care Project impressed upon me the challenges in treating older persons with cardiovascular disease, which typically occurs in conjunction with many other conditions. Our team characterized the marked discrepancy between the “real world” population treated in clinical practice and those enrolled in trials (Am Heart J 2003); the increasingly complex and costly medication regimens for heart failure in older persons (Arch Intern Med 2005); and the prescription of potentially harmful medications in this vulnerable population (JAMA 2003 and Circulation 2005).

In parallel, my clinical experiences were teaching me that the care of older persons with cardiovascular disease wasn’t all about cardiology and that the reductionist approach implicit to treatment guidelines didn’t fit this population. When listening to older people talk about their experiences, it was clear that cardiovascular disease wasn’t always the most important issue; that some patients prioritized quality of life over longevity for its own sake; that social support and potential threats to independence played an increasingly important role. Taking care of older patients with numerous conditions was clearly nuanced and required a willingness to look beyond the constraints of the data generated from the rarified environs of clinical trials.

The cardiovascular profession is acknowledging these lessons more broadly. The American College of Cardiology (ACC) has a robust Geriatric Cardiology Section, which has advocated for an emphasis on the specific challenges in caring for complex older patients throughout the organization. The ACC has also engaged in the development of instruments to support shared decision-making, which while important for all patients, is often even more important in the older population. The ACC, in partnership with the American Heart Association, are also committed to integrating considerations relevant to the older population in its practice guidelines. The confluence of these efforts is likely to transform how cardiologists approach the care of older persons in clinical practice.

I remember when saying “I’m a cardiologist” in the company of geriatricians felt like a 12-step program confession. Fortunately, those days are behind me. I am optimistic that through collaboration between geriatricians and cardiovascular specialists, like the Patients’ Priorities Care Program, will help all of us deliver the right care to the right patient in accordance with their personal values.

 

By: Fred Masoudi, MD

Rethinking Endpoints: The Rise of Function

dodson%20headshotThe American Heart Association recently released a Scientific Statement on prioritizing functional capacity as an end point for treating older adults with cardiovascular disease.  A major rationale is that older patients repeatedly cite preservation of physical function as an outcome that matters most to them; for example in a landmark study by Fried et al. in 2002, survey respondents (older adults with limited life expectancy) reported that nearly three quarters would decline a treatment if the outcome was survival with severe functional impairment.

The AHA Statement highlights some key concepts when considering how to think about functional capacity in our everyday practice. I have highlighted several which I think are especially important:

  1. Function in older adults (and functional decline) is multifactorial. Function is determined not only by cardiovascular health, but by other organ systems including skeletal muscle, bone, lungs, and brain. For example, cognitive impairment may cause significant functional impairment despite normal cardiac output. This underscores why Geriatric Cardiologists aim to “think outside the heart” in addressing older patients’ symptoms.
  2. Trials that move beyond the traditional endpoints of death and/or cardiac events may be particularly relevant to older adults. Not many trials to date have accomplished this; however the authors cite the ASPREE trial (Aspirin in Reducing Events in the Elderly) as a novel example, using a primary end point of disability-free life (dementia and persistent disability).
  3. There are many domains of function, including aerobic, strength, balance, and cognition. Each domain also has multiple ways to measure it. It is simply impractical to measure all domains in everyday clinical practice. But a multi-domain assessment such as the Short Physical Performance Battery (SPPB), which assesses balance, mobility, and gait speed, can be completed in 10-12 minutes. I would expect these assessments to become more commonplace is specific settings, such as preoperative risk evaluation.

Finally, the article also discusses the critical need for interventions to improve or maintain function in older adults. Given the heterogeneity of abilities in older patients, rather than a “one size fits all” approach, these are best tailored towards specific goals (e.g. climbing stairs, household chores). A key role for Geriatric Cardiology will be to evaluate which interventions work best, and figure out how to embed them in everyday clinical practice.

By: John Dodson, MD