Does care coordination reduce costs? (and does this matter)?

dodson%20headshotThe “post-hospital syndrome” has been used to describe the vulnerable period after older patients are discharged from the hospital. The basic hypothesis is that in-hospital factors such as sleep deprivation, poor nutrition, immobility, medication changes, and complex instructions all make patients at-risk for adverse events such as hospital readmission. In practice, most of us have seen this phenomenon in our older patients at one point or another.

Intuitively, being good at coordinating care for older adults after they are discharged should lead to both better outcomes and cost savings. The health system can be incredibly challenging for older patients to navigate. Care coordination can include activities such as ensuring a patient has timely access to an outpatient visit after hospital discharge; evaluating whether they have their needed medications; and facilitating that primary care and specialist care plans are aligned. All of these have the potential to prevent adverse events for patients (e.g. missing a dose of needed medication) and therefore plausibly lead to cost savings through reducing harmful events.

I was therefore intrigued by a recent editorial in the New England Journal of Medicine that called into question exactly how much cost savings care coordination achieves. The author points out that care coordination itself costs money; both in terms of personnel (care coordinators) and information health technology. Moreover, a large number of patients may need to have their care properly “coordinated” in order to measurably prevent a single adverse event. The article goes on to highlight that care coordination is politically more palatable than other approaches to cost reduction, such as restricting access or rationing. This likely explains the broad enthusiasm for it, even if is not necessarily the most cost effective option.

Is care coordination still the appropriate thing to do? I think so. I have had several particularly complex older patients where a dedicated care coordinator made the difference between a good outcome (e.g. reducing redundant medications, making sure that all specialists were on the same page) and a bad one. But perhaps we need to weigh care coordination on merits other than cost – such as how it can improve patients’ experience with the health system – in order to ensure its long-term viability.

 

By: John Dodson, MD

 

Rethinking How a Clinician Discusses Management in Older Adults With Multiple Chronic Conditions

ashok-krishnaswamiAs a non-invasive geriatric cardiologist, I am proud of the fact that I spend a large proportion of a clinic visit or hospital consultation speaking with my patients and their families about their medical or procedural management plan(s). I obsess over their understanding of the topic.  I would like patients and families to make the best choice with all the available information. However, I have to honestly state, these discussions thoroughly exhaust me. It is time consuming and often difficult when patients and families do not have the sufficient skillset to comprehend the information. Tools such as pictorial decision aids are now being used to improve comprehension by patients and their families of this shared decision-making process. However, improvements in the implementation of these tools are needed.

Broadly speaking, Cardiology has often focused on single-disease cardiovascular states. However, Geriatric Cardiology welcomes with open arms the complexity of multiple conditions tied to the index cardiac disease. Appropriately, both are tied to value. However, value is defined differently in Geriatric Cardiology. A recent (March 16, 2016) JAMA Cardiology viewpoint addressed the concept of patient value based care. The authors defined value as a simple formula (Value = Health Outcome/ Cost).  From the broader Cardiology perspective, health outcomes are typically mortality, myocardial infarction, stroke; and cost is most often seen as the financial cost. From the Geriatric Cardiology perspective, health outcomes can encompass a myriad of other states. These patient centered outcomes  (“Doc, I want to be able to walk 2-3 blocks everyday, be able to work for another year, to see a favorite football sports team in the super bowl” etc.) are starkly different from the previous ones, in that they prioritize personal patient experience and quality of life. Within this patient centered perspective, cost is considered to include willingness to get labs, diet, exercise, regularly attend clinic, diligently take medication, report adverse reactions, undergo procedures, as well as financial costs.

The wonderful promise of this new formula is its hope for improving the quality of discussions between patients and clinicians. In my opinion, incorporating this formula into a larger, clinical, decision-making framework that includes concepts such as life expectancy assessments, risk scores based on geriatric specific syndromes, lag time to benefit, and competing risks, will further this field greatly by reorganizing our priorities for what is best for the patient on a qualitative and individual level.

By: Ashok Krishnaswami, MD, MAS

Clinical Innovations: The Geriatric Cardiology Conference

adam-skolnick_headshotWe just had our 16th interdisciplinary, patient-centered, Geriatric Cardiology Conference here at NYU. It is heartening to see so many experts (geriatric and cardiology physicians, nurse practitioners, fellows, surgeons, palliative care specialists, and medical students) sitting in one room together. With today’s compartmentalization of medical fields, specialists do not often meet to discuss patients who are at the intersection of multiple disciplines. This conference is a clinical innovation that was created with the intention of addressing that problem for older adults with complex cardiovascular issues.  Our diverse group meets once a month to discuss 1-2 active patients who have come to a clinical crossroads.  All patients are presented in a standard format and the group of attendees comes to a consensus on each clinical question at hand.  The referring physician receives a summary letter stating the final opinion of the group.  Our ultimate hope is that this interdisciplinary conference will serve as a paradigm for similar programs nationwide.

 

By: Adam Skolnick, MD

The Business Case for Talking More to Patients

dodson%20headshotTime remains one of the most critical elements in providing high-quality care for older patients. This seems intuitive: decisions are often complex, family members are frequently involved, and aging-related impairments themselves (such as difficulty hearing) may hinder communication. Despite this, clinicians face enormous pressures to make visits shorter in order to maximize volume, even with complicated older patients.

So I was intrigued by a recent Perspective piece in New England Journal of Medicine which argued that, aside from being the right thing to do, spending more time with patients can actually be cost-effective. The authors illustrated several cases where detailed conversations can avoid extensive downstream healthcare costs – for example, a prolonged anticipatory discussion about dialysis planning ($200) can markedly reduce the likelihood of complications from hastily placed dialysis catheters ($20,000). As another example, a multidisciplinary oncology conference among experts that spent 5 minutes per patient changed treatment plans nearly one-third of the time, potentially avoiding improper (and expensive) downstream care.

I think these studies underscore what many patients and clinicians intuitively know: that time is one of our most valuable resources. Moving forward, it will be interesting to see whether the “value” of these conversations increases, especially when caring for older adults, as the evidence keeps accumulating and we move towards new models of reimbursement.

 

By: John Dodson, MD

Welcome Message

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Welcome to aginghearts.org. We created this website with the aim of raising awareness about geriatric cardiology which is a relatively new but growing discipline. Briefly, geriatric cardiology aims to merge principles of geriatrics (such as assessment of function, cognition, and individualized goals of care) into the care of patients with cardiovascular disease; with the aging of the population, this field is only going to grow in importance in the coming years.

In addition to aggregating content related to geriatric cardiology, our website will feature blog posts where we’ll gain perspective from healthcare professionals, trainees, patients, and caregivers about aging and cardiovascular disease.

The article by Bell and colleagues about “What to Expect from the Emerging Field of Geriatric Cardiology” provides an excellent summary of the current state and future directions of our discipline.

By: John Dodson, MD