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Friday, April 26, 2013

What does expensive care look like and who are the 1% of patients who use over 22% of health care expenditures?

I have been working almost exclusively in hospitals for the last 17 months and I often get a chance to rub shoulders with the 1%, that is to say the people whose poor health puts them in the position to spend more healthcare dollars than the other 99% of the US population.

At the opening speech of the American College of Physicians annual meeting a few weeks ago Ezekial Emmanuel, an adviser to the US Office of Management and Budget and head of the department of Medical Ethics and Health Policy at the University of Pennsylvania gave some interesting statistics. In the United States, 1% of patients at the highest level of medical spending are responsible for 22% of healthcare costs and the bottom 50% of healthcare utilizers use a little over 3%. I looked at the article, from the Agency for Healthcare Research and Quality, and found that this percentage is relatively stable over many years, and, in fact, the costs are slightly less concentrated in the upper 1% than they were in 1996. Also, and maybe more dramatically, the top 5% of patients consume about half of healthcare costs.

So, after hearing these figures, I paid really good attention to the patients I saw in the hospital, trying to see who was most likely in that top 1%. Patients in the hospital are probably going to be the people who consume the greatest amount of resources, since hospital costs are by far the largest share of US medical expenditures. In 2011, hospital costs were over $850 billion, topping doctor and clinical services at $541 billion and prescription costs at $263 billion. The breakdown of total healthcare costs is pretty interesting and can be found here, at the Center for Medicare Services (CMS.)

The patients at the hospital who use the most resources are people with chronic diseases, the old and sometimes the very old, often poor people on public insurance, either Medicare or Medicaid, and occasionally the outlier who has been extremely unfortunate or spectacularly unwise. They are often obese and many smoke cigarettes, drink excessive alcohol or use damaging illicit drugs. Frequently they have chronic pain and are on regular doses of opiates and other sedating drugs. Many are depressed. These are patients who have been in the hospital for a very long time, usually in and out of the intensive care unit, often with multiple surgical procedures or specialist driven interventions. They have long lists of medications and are likely to have experienced some sort of medical complication due to the complexity of their care.

It is very hard to care for the 1%. They have had so many tests that it takes extremely keen data management skills to make sure that all of the incidental abnormalities are followed up and that procedures that have already been done are not repeated. Their medication lists are hard to follow, and rationale for care is difficult to tease out from medical records. They are often frustrated and jaded with caregivers because they have seen so many mistakes and heard so many contradictory explanations and plans from their many specialists and rotating hospitalists. Some of them will never be well, but nobody will take the time to explain this, and even if a doctor did take the time, the patient finds it difficult to trust that they know what's going on.

The 1% have had just about everything done to them. In some cases this means that they no longer want anything medical for the rest of their lives. More often, though, they have been through hell and it doesn't seem so bad, and so they would do it again. I see this pretty often with patients on renal dialysis. Out of a total Medicare budget of over $522.8 billion dollars in 2010, $32.9 billion was spent on patients with endstage renal disease (ESRD), who made up a little over 1% of the Medicare insured population. Patients with ESRD do not have enough kidney function to survive without regular dialysis, usually 3 times weekly. For most of these patients this means several hours at a dialysis center where their blood is circulated through a series of filters which act as an artificial kidney. Fluid is removed, electrolytes are adjusted and toxins are filtered out. Sometimes medications such as antibiotics or blood cell stimulants are administered. Patients on dialysis are dependent on machines for life support, though they can walk around between sessions and do regular person things. Usually, to be on dialysis, a person has been sick a long time, and the kidneys are not the only organs that have suffered, so most patients with ESRD are at least a little bit sick all the time. Most are disabled from work, and the majority are not able to pursue an active life.

Other patients in the 1% are the old and very old, people over the age of 80, often with multiple chronic medical problems, at least one of which decompensates and lands them in the hospital. As a hospitalist, I often have the opportunity to talk to these patients or their family members about goals of care. Sometimes I find that they want a reasonable attempt to cure the problem at hand with the expectation of being able to return to home or nursing home with about the same level of function as before they got sick, and that they understand that it is also possible that an illness that is so bad that it lands them in the hospital might also be fatal or lead to an unacceptable level of disability. We then address the question of "code status", whether they would want to have chest compressions and be on a ventilator should vital functions cease, and I explain that, in a person such as they, none of this is likely to be effective in bringing them back to life. The actual percentage of success for CPR in this population is about 5%. The downside of CPR, I will explain, is that it means that they will not have a peaceful death, and often it will be painful and traumatic. It is hard to have this talk, because it makes the poor patient imagine their death, hardly the comfort I would prefer to be offering. Some patients have already thought it through, and even before the discussion is under way they tell me that they have had a good life and when their time comes they would like to be allowed to depart in peace. Some will hear the whole discussion and say "I think I'd like you to just give it a try and if it doesn't work, don't have me live forever on machines like a vegetable." This is then translated into a very simple medical order, "full code", and the patient will then get just about every medical procedure available that might even remotely lengthen their life until such time that any observer would consider that they are just being kept alive on machines like a vegetable, at which time life support is gently discontinued. The process of getting to comfort care from cardiac resuscitation can be quick, but more often involves an agonizing period in which a loved one is festooned with tubes and wires, pale, miserable, helpless and confused.  "Full code" for the patient with multiple medical problems is a terrible thing.

Another 1% patient is the drug abuser or alcoholic, usually also a smoker. Some of these patients have pretty amazing stories. They have lived on the edge of the world for so long that being in the hospital is not necessarily any more dramatic than the rest of their lives. They develop blood stream infections, skin and muscle abscesses, AIDS and its complications, hepatitis C and its complications, cirrhosis of the liver with massive bellies and stick-like arms and legs. They come in to the hospital on multiple occasions, so sick we think they must die, and then recover, only to go out and do it all again. They want everything done, have no money or insurance to pay for it, and often leave against medical advice before we are even done treating them. Wow.

A smaller proportion of super healthcare utilizers have cancer, despite the fact that they lived well and are still young. They have genetic diseases such as cystic fibrosis, have organ transplants or bone marrow transplants or are babies born too early. Or they were hit by a car and developed multi-organ failure. Or they were bitten by a rodent with the plague and developed shock and had their limbs amputated. Or something else horrible happened that we could all stay up nights worrying about.

So what does it all mean and what should we do about it? Clearly a healthcare dollar buys much more happiness in the bottom 50% of Americans who make up only 3% of all healthcare spending. For these folks, their pneumonia is cured by an oral antibiotic or their broken arm is set and splinted or their head laceration is sewn up or they receive effective contraception or other preventive services which keep them on their feet, happy and functional. For the very sickest, a healthcare dollar buys close to nothing, no joy, no productivity, maybe one saline flush after the dose of antibiotic goes in.

I truly don't know what to do about it. It is not right that folks who persist in self abuse use resources over and over while the working poor can't even afford basic healthcare. But it is also not up to me to police the choices that people make about how to live their lives. It is not right that huge amounts of money are spent to minimally lengthen the lives of the very old. Most of the very old with whom I have had this conversation agree heartily on that point. It is not right that physicians continue to advise very expensive technological care for patients near the end of life, especially since research shows (at least with lung cancer) that a palliative care approach both lengthens life for those patients and improves its quality. I think that "full code" should not be the default assumption in patients for whom the likelihood of it being effective is very low. I think that it is up to us, as physicians, to figure out some way to educate our patients about this. Perhaps we need an advertising campaign to "Live well, die in peace," complete with a very accurate depiction of resuscitation versus a comfort care approach at the end of life. We need to change  our payment structures so that it doesn't benefit us, as doctors or hospitals, to make patients dependent upon us. We need to have an accurate idea of costs and feel comfortable bringing them into discussions with our patients. Primary care doctors need to have the time and expertise to discuss resuscitation with patients (who know and trust them) as they age and develop chronic medical problems. We all need to take more time to think about the what these many tests and treatments we prescribe are really good for and be a little more focused about applying them. If we reduce the complexity of the care we provide, we will free up time and energy to actually sit and listen to our patients, a much neglected but often magically effective treatment strategy.

Wednesday, April 17, 2013

How to learn bedside (point of care) ultrasound: tips for the interested internist

I first picked up an ultrasound transducer 17 months ago, at Vicki Noble MD's emergency medicine ultrasound course at Harvard University. I had just barely heard about using ultrasound as a clinical tool and was vaguely interested. The course was 3 days long and cost a little under $700 and changed my life forever and made me a better doctor.

Emergency physicians have embraced the use of ultrasound at the bedside for many years and the vast majority of physicians who complete emergency medicine residencies are competent in using ultrasound for procedures and diagnosis. In bedside ultrasound, the doctor who examines the patient also does the ultrasound, often with a small portable machine, checking out the heart, lungs and other internal organs as part of the physical exam.  Internal medicine physicians have been very slow to pick up this technology, probably mostly because the equipment has been a little too large to be convenient and training to wield the probe and interpret the images takes time and is inaccessible. The American Academy of Chest Physicians (ACCP) is the professional organization that represents critical care and pulmonary doctors, and their journal, Chest, has recently adopted ultrasound education via an online section called the Ultrasound Corner. The editorial by Seth Koenig MD accurately describes the power of the technique in critically ill patients, and the educational offerings of the ACCP for intensivists.

So, first of all, why might an internist want to learn bedside ultrasound and how might it be merged effortlessly into patient care? When I see a patient now, instead of taking their pulse and placing my stethoscope on their chest and back, hearing the vague taps and clunks and bubbles and whooshes of the internal organs I have come to trust are in there, I open the ultrasound machine that lives in my white coat, squeeze a little gel from a tube I keep warm in my pocket, and the patient and I look at heart, lungs, liver, spleen, kidneys and bladder. Most of them, those not blind or in a coma, think this is incredibly cool. At the end of this exam, which takes all of 5 minutes if I am thorough, I know whether their heart squeezes normally, whether there is excess fluid in the lungs or pericardial sack, whether there is fluid in the belly, whether the kidneys are blocked and whether the bladder is emptying normally. Sometimes I also see things like gallstones or tumors or blood clots. I can often evaluate whether the patient is dehydrated by looking at the inferior vena cava, the vein that returns blood from the lower body to the heart.

If a patient loses consciousness, like one of them just did today, I can quickly rule out a major heart attack as the cause of the problem. My little machine is not quite as sensitive as the huge expensive ultrasound machines, but it is pretty good and I can usually be sure about the answers to the questions that are most vital to treating my patients immediately.  If a patient has chest pain and my ultrasound of their heart is good, I can be much more confident about whether the chest pain is due to a heart attack. Several times since I have been doing this, I have found an unexpectedly poorly functioning heart in a patient whose story of chest pain was not particularly convincing for coronary artery disease and was able to advocate for quick or aggressive treatment which expedited treatment and saved heart muscle. The ability to evaluate bladder size is powerful. The ability to rule out hydronephrosis (urine backed up in the kidneys) allows me to avoid excessive imaging in patients who have a change in their kidney function. We often see patients with big bellies who may or may not have excess fluid due to cancer or liver failure or heart failure, and it is so very convenient to be able to make the distinction between fat and fluid without waiting for an imaging procedure to be done.

But how does a person learn how? I took 3 emergency ultrasound CME classes with live models and hands on instruction, one on line ACCP class in critical care ultrasound and bought the pocket Vscan ultrasound from GE which I use at least once on just about every patient, friend and family member. The dog has barely escaped due to excess fur. I then took a mini ultrasound fellowship with the department of emergency ultrasound at UC Irvine under the direction of Chris Fox MD. This involved 4 weeks of scanning in the ER, going over saved scans, teaching medical students and studying online material. It was kind of expensive: $5000 for the fellowship and 4 weeks off of work in a place where I had to stay at a hotel. But I am way better at it than I was, I know what the protocols are and can do ultrasound of things that internists don't usually examine that way, including eyeballs and uteruses and testicles and thyroids and skin structures. My Vscan doesn't have a linear transducer, so I haven't been able to improve as fast at procedures that need shallow scanning, such as blood vessels, muscles and joints. I'm thinking that I will need to have access to a machine that I can use whenever I want, so I will probably buy an ultrasound machine with a linear transducer from China where the technology costs about 1/10th what it does here.

There are other ways to learn bedside ultrasound, including year long fellowships, which are usually based in emergency rooms. There is a program at Harvard that lasts 5 or 10 days that involves participating in scanning at the radiology department, and reviewing many scans every day. I would love to do that. The limitation of learning ultrasound techniques from real ultrasonographers and radiologists is that they do a more thorough exam than we usually have time for, and the perfect protocol for quickly determining relevant information in an internal medicine patient is not the same as what an ultrasonographer does when we order specific tests. The ACCP has excellent courses with live patient scanning, which are apparently quite expensive. I would also love to take one of these. There are many for-profit groups that offer training as well. It's not hard to find a course that will get a person started, but it does take many hours of practice and the ability to review scans with experts in order to feel comfortable. If our hospitals or clinics decided to embrace bedside ultrasound, and radiologists bought into it (and I actually think they would) we could really benefit from the teaching of our radiology technicians and MD radiologists.

It continues to astonish me how much more effective I am as a doctor with an ultrasound than I was as a doctor without one. I make diagnoses I wouldn't have thought of, save patients radiation and hospital days and quickly have information I need to focus treatment. I understand why my busy colleagues haven't embraced this technology yet, but when they do they are going to love it!

Tuesday, April 16, 2013

Attending the Annual Meeting of the American College of Physicians in San Francisco 2013: becoming a fellow


The American College of Physicians is an organization of internal medicine doctors, about 133,000 of us, which had its inception in 1915 with the aim of promoting the science and practice of medicine. It is the second largest doctors’ group in the United States, and has members and chapters  throughout the world.  The college has representation in the American Medical Association and influences government health policy.  

The ACP had its annual meeting this year in San Francisco, which is a wonderful place. It was located at the Moscone Center, a big convention hall with gorgeous architecture, and the weather was spectacular. It was right near Chinatown, so I didn't have to eat the overpriced pastries and coffee from the convention vendors, or sell my soul to the devil by eating what the industry sponsors supplied in the hall of evil advertisers. 

I went this year because I was receiving my fellowship in the college. If an internist has been doing medicine for long enough and has distinguished him or herself in some way, in my case by learning and teaching, he or she can be awarded a fellowship in the American College of Physicians. It is necessary that the physician in question be a member of the college, which is a yearly commitment of $525 for me, since I am out of school more than 8 years. It is then necessary to pay an additional $150 for fellowship initiation and have two present fellows write letters of recommendation. There are various categories of being distinguished that one can fall into, which are outlined in the Advancing to Fellowship section of the ACP site. I'm not entirely sure that it means anything, really, but I thought that it would help me to express to people who I wanted to work with in the medical world that I am not a bozo. After being advanced to fellowship, I now can put four more letters after my name: after MD comes FACP, which does look kind of nice.

There were 3000 new fellows this year, 500 of whom went to the ACP meeting, wore graduation gowns and caps and were recognized at the convocation ceremony. Also a much smaller group of doctors received Masters recognition, and quite a few received specific awards for things like research and teaching and service. I usually prefer not to go to ceremonies because they are tedious, and this was a little tedious but also wonderful in some ways. I realized as I watched the folks getting the Masters recognition that these were the grand old men and women of medicine and that their life stories were probably fascinating and filled with sacrifice and dedication and hard work. Also the president of the college, who struck me as a person who would not give a good talk, gave a very good talk. Dr. David Bronson has been involved in all of this ACP business for years, but distinguished himself in preventive medicine at the Cleveland Clinic as an internist. He pulled no punches in his speech, which I will not paraphrase since I would certainly not say it as well. What I heard, though, was that we, as part of the American healthcare system, are responsible for how expensive and ineffective it has become and we need to pull together and fix it, and it will take a long time and a lot of work. He also recognized that many of us are already doing that work and that it is important. He gave lots of details, which I probably have deep in my gray matter somewhere and showed a brief film which reminded me to be as empathic as humanly possible, and we filed out. We returned our regalia and were then done. 

But that wasn't the most interesting part of the annual meeting. The "Scientific Sessions" (actually just lectures by experts) were excellent, covering all of the major high points in internal medicine practice. Some of the talks dealt with things like giving a talk that isn't boring and providing effective leadership, not being wasteful of our patients resources and avoiding errors of miscommunication. It was possible to attend only a small fraction of these, and then, if one was really motivated, shell out more money (the conference itself was pretty expensive) for recordings of all of the sessions. I was impressed with most of the speakers who had really prepared and presented subjects that they appeared to find fascinating in a way that was engaging. I learned a great deal and expect to learn more when my CDs of the rest of the meeting arrive. 

Naturally I was disappointed in the fact that bedside ultrasound, which is clearly transformative for internists, had very little air time in the meeting. There was one workshop in bedside ultrasound of the heart and abdomen, and that was so popular that the waiting list had over 100 people on it. I didn't go, since I have now had enough bedside ultrasound training that I could probably teach it, but it is clear to me that internists are aware of the importance of this and only lack time and teachers at this point. In talks about things like assessing patients with chest pain or sepsis, bedside ultrasound was not even mentioned, which didn't surprise me, but it would have been good to see that these influential folks were moving in the right direction. General Electric, which makes the pocket ultrasound machine that I use, and that internists would find most convenient in their practice, exhibited only one product, a radio tracer, analog of cocaine, which deposits itself in the brain in such a way as to differentiate benign essential tremor from Parkinson's disease, which is hardly transformative, and probably mostly superfluous. 

I probably won't go to the ACP meeting next year, since it is in Orlando, Florida, which is pretty far off of my usual stomping grounds. Still, I am happy about the general direction that the ACP is taking, with real leadership in turning medicine into a leaner and more effective service. 

Friday, April 5, 2013

Hospital readmissions: what exactly is the deal with this?

Medicare has been costing the government a scary amount of money for many years, and the very popular program, established in 1965 under President Lyndon Johnson to pay for health care for seniors, has undergone many changes since its inception. Because the government funded program was a very deep pocket from which the sick could pay hospitals and doctors, it influenced the cost of medicine and the volume of health care in a pretty profound way.

In 1983 Medicare began to pay hospitals for care of patients in a way that was felt to be likely to reduce unnecessary and expensive care. This was the Inpatient Prospective Payment System, the IPPS.  Instead of paying a hospital for everything that was done to a particular patient, which would potentially encourage higher costs and higher utilization of services, Medicare began to pay hospitals a certain amount for each kind of sickness. These categories of sickness were called Diagnostic Related Groups (DRGs). If a patient had a particularly bad pneumonia, the hospital would get a certain amount of money, encouraging them to treat the patient as quickly and cheaply as possible. Doctors were still paid according to how much they did, but hospitals received a bundled payment for stuff such as bags of IV fluid and antibiotics and CT scans. Many hospitals closed, and the ones that survived learned to discharge patients earlier, use less expensive resources, use the DRGs that paid the most (as much as they could without defrauding the government) and also shifted some of the costs to patients who were insured by private companies.

There was concern that hospitals could game the system by discharging a patient, potentially too early for the patient to really make it at home, and then readmit the patient to the hospital and get paid again. And, indeed, that does happen. As physicians we were (and are) strongly encouraged to get our patients out of the hospital at the first reasonable moment, and the constant nagging and puppy eyes of the discharge planners would often make us send patients home before we felt it was wise to do so.

In 2011 Medicare announced that it would pay hospitals less for taking care of patients if records showed that the hospitals had too many readmissions of Medicare insured patients within 30 days of discharge. This is really quite a random number, based loosely on how long it takes the moon to orbit the earth (actually 27.3 days.) It was thought that, if a patient came into a hospital, got fixed up properly and was discharged, that patient should stay well for slightly longer than it takes the moon to go around the earth. So if that patient came back to the hospital before the moon made it entirely around the earth, it was likely that some mistake or carelessness had been committed. Equally randomly, it seems to me, they decided to look at just three diagnoses, heart failure, myocardial infarction and pneumonia, to start with.

I'm all for punishing hospitals for convincing me to discharge patients early against my better judgement, but that is not what is happening, in my recent experience.

I have taken care of several patients, readmitted before 30 days had passed, in the last few weeks. Their stories are varied, but don't really represent poor care. The JAMA (Journal of the AMA) has occasionally visited the concept of hospital readmissions, and some of the articles are excellent, exploring the idea that readmissions don't necessarily represent dangerous care and that they are indicative of a population of patients who don't have adequate access to good medical care outside of the hospital (look at this article for a good discussion, though you only get the first page because JAMA is proprietary.)

So I'd like to look at some of the examples to see if there is a pattern.

1. 50 year old man with alcoholic cirrhosis who lives on the street and has just recently been diagnosed. He has no insurance and no regular doctor, and though we give him an appointment to see a doctor after each discharge, he never makes it to these appointments, sometimes because he gets sick with massive ascites before he can get there.

2. 88 year old woman, discharged after a long battle with pneumonia to her home and pets, returns to the hospital weak and short of breath. She appears to have worsening chronic lung disease on further evaluation and be too weak to return home. It was still worth a try!

3. 29 year old woman, uninsured and with very bad luck and 2 forms of cancer, discharged to assisted living, returns in a day, short of breath and anxious. She has been too anxious to actually take her anxiety medications, and hasn't yet seen her oncologist back for treatment of both cancers which are still quite active.

4. 60 year old man with dialysis dependent kidney disease who was very grouchy and obstructive in the hospital, returns after a day in a nursing home because he is grouchy and obstructive.

5. 87 year old woman with end-stage kidney disease, also on dialysis, has been in the hospital approximately once per lunar orbit for 18 months for problems such as pneumonia and urinary tract infection, admitted with shortness of breath and a large collection of fluid in both lungs.

I'm thinking that a really great and very motivated outpatient doctor who goes the distance and visits patients in their homes and treats patients for free and lets the homeless ones crash on her couch could have averted all of these readmissions. I'm also thinking that this particular doctor is not just a dying breed but virtually nonexistent. In the absence of this doctor of whom legends are written and ballads are sung, a good hospital will continue to be a (very expensive) refuge. The costs to those patients who have no insurance in this group is huge, but they have no resources and will never pay, and the hospital knows this and stays afloat in some other way. It's hard to know what to do with our well established cultural belief that everyone needs dialysis at the end of life unless they vigorously oppose it, which is what results in frequent readmissions of patients with end-stage kidney disease. Clearly the fact that a hospital is usually the only place that a person with no resources whatsoever can get good medical care will continue to drive frequent readmissions of this group of people.