Paradigm shifts in palliative care

 

A 57-year-old man is admitted to the hospital with new back pain, which has been getting worse over the past 6 days. He had been diagnosed with stage 4 lung cancer in mid-2017 and underwent treatment with a platinum-based double therapy.

The man also has a history of heroin use – as recently as two years earlier – and he was divorced not long ago. He has been using an old prescription for Vicodin to treat himself, taking as many as 10-12 tablets a day.

This man is an example of the kind of complicated patient hospitalists are called on to treat – complex pain in an era when opioid abuse is considered a public scourge. How is a hospitalist to handle a case like this?

Pain cases are far from the only types of increasingly complex, often palliative cases in which hospitalists are being asked to provide help. Care for the elderly is also becoming increasingly difficult as the U.S. population ages and as hospitalists step in to provide care in the absence of geriatricians. .

Pain management in the opioid era and the need for new approaches in elderly care were highlighted at the Hospital Medicine 2018 annual conference, with experts drawing attention to subtleties that are often overlooked in these sometimes desperate cases.

James Risser, MD, medical director of palliative care at Regions Hospital in Minneapolis, said the complex problems of the 57-year-old man with back pain amounted to an example of “pain’s greatest hits.”

That particular case underscores the need to identify individual types of pain, he said, because they all need to be handled differently. If hospitalists don’t consider all the different aspects of pain, a patient might endure more suffering than necessary.

“All of this pain is swirling around in a very complicated patient,” Dr. Risser said, noting that it is important to “tease out the individual parts” of a complex patient’s history.

“Pain is a very complicated construct, from the physical to the neurological to the emotional,” Dr. Risser said. “Pain is a subjective experience, and the way people interact with their pain really depends not just on physical pain but also their psychological state, their social state, and even their spiritual state.”

Understanding this array of causes has led Dr. Risser to approach the problem of pain from different angles – including perspectives that might not be traditional, he said.

“One of the things that I’ve gotten better at is taking a spiritual history,” he said. “I don’t know if that’s part of everybody’s armamentarium. But if you’re dealing with people who are very, very sick, sometimes that’s the fundamental fabric of how they live and how they die. If there are unresolved issues along those lines, it’s possible they could be experiencing their pain in a different or more severe way.”
 

Varieties of pain

Treatment depends on the pain type, Dr. Risser said. Somatic pain often responds to nonsteroidal anti-inflammatories or steroids.

ah_designs/Getty Images

Neuropathic pain usually responds poorly to anti-inflammatories and to opioids. There is some research suggesting methadone could be helpful, but the data are not very strong. The most common medications prescribed are antiseizure medications and antidepressants, such as gabapentin and serotonin, and norepinephrine reuptake inhibitors.

The question of cancer pain versus noncancer pain can be tricky, Dr. Risser said. If a person’s life expectancy is limited, there can be a reason, or even a requirement, to use higher-risk medications. But, he said, that doesn’t mean the patient still won’t have problems with overuse of pain medication.

“We have a lot of patients now living post cancer who have been put on methadone or have been put on Oxycontin, and now we’re trying to figure out what to do with them,” he said. “I don’t think it’s that clear anymore that there’s a massive difference between cancer and noncancer pain, especially for those survivors.”

Clinicians, he said, should “fix what can be fixed” – and with the right tools. “If you have a patient who’s got severe lower abdominal pain because they have a bladder full or urine, really the treatment would probably not be … opioids. It probably would be a Foley catheter,” he said.

Hospitalists should treat patients based on sound principles of pain management, Dr. Risser said, but “while you try to create a diagnostic framework, know that people continually defy the boxes we put them in.”

Indeed, in an era of pain-medication addiction, it might be a good idea to worry about prescribing opioids, but clinicians have to remember that their goal is to help patients get relief – and that they themselves bring biases to the table, said Amy Davis, DO, MS, of Drexel University, Philadelphia.

In a presentation at HM18, Dr. Davis displayed images of a variety of patients on a large screen – different races and genders, some in business attire, some rougher around the edges.

“Would pain decisions change based on what people look like?” she asked. “Can you really spot who the drug traffickers are? We need to remember that our biases play a huge role not only in the treatment of our patients but in their outcomes. I’m challenging everybody to start thinking about these folks not as drug-seekers but as comfort-seekers.”

When it comes right down to it, she said, patients want a better life, not their drug of choice.

“That is the nature of the disease. [The illegal drug] is not what they’re looking for in reality because that does not provide a good quality of life,” Dr. Davis said. “The [practice of medicine] is supposed to be about helping people live their lives, not just checking off boxes.”

People with an opioid use disorder are physically different, she said. The processing of pain stimuli by their brain and spinal cord is physically altered – they have an increased perception of pain and lower pain tolerance.

“This is not a character flaw,” Dr. Davis affirmed. The increased sensitivity to pain does not resolve with opioid cessation; it can last for decades. Clinicians may need to spend more time interacting with certain patients to get a sense of the physical and nonphysical pain from which they suffer.

“Consistent, open, nonjudgmental communication improves not only the information we gather from patients and families, but it actually changes the adherence,” Dr. Davis said. “Ultimately the treatment outcomes are what all of this is about.”
 

 

Paradigm shift

Another palliative care role that hospitalists often find themselves in is “comforter” of elderly patients.

Dan Burke Photography

Ryan Greysen, MD, MHS, chief of hospital medicine at the University of Pennsylvania, Philadelphia, said hospitals must respond to a shift in the paradigm of elderly care. To explain the nature of this change, he referenced the “paradigm shift” model devised by the philosopher of science Thomas Kuhn, PhD. According to Kuhn, science proceeds in a settled pattern for many years, but on the rare occasions, when there is a fundamental drift in thinking, new problems present themselves and put the old model in a crisis mode, which prompts an intellectual revolution and a shift in the paradigm itself.

“This is a way of thinking about changes in scientific paradigms, but I think it works in clinical practice as well,” Dr. Greysen said.

The need for a paradigm shift in the care of elderly inpatients has largely to do with demographics. By 2050, the number of people aged 65 years and older is expected to be about 80 million, roughly double what it was in 2000. The number of people aged 85 years and up is expected to be about 20 million, or about four times the total in 2000.

In 2010, 40% of the hospitalized population was over 65 years. In 2030, that will flip: Only 40% of inpatients will be under 65 years. This will mean that hospitalists must care for more patients who are older, and the patients themselves will have more complicated medical issues.

“To be ready for the aging century, we must be better able to adapt and address those things that affect seniors,” Dr. Greysen said. With the number of geriatricians falling, much more of this care will fall to hospitalists, he said.

More attention must be paid to the potential harms of hospital-based care to older patients: decreased muscle strength and aerobic capacity, vasomotor instability, lower bone density, poor ventilation, altered thirst and nutrition, and fragile skin, among others, Dr. Greysen said.

In a study published in 2015, Dr. Greysen assessed outcomes for elderly patients who were assessed before hospitalization for functional impairment. The more impaired they were, the more likely they were to be readmitted within 30 days of discharge – from a 13.5% readmission rate for those with no impairment up to 18.2% for those considered to have “dependency” in three or more activities of daily living.¹

In another analysis, severe functional impairment – dependency in at least two activities of daily living – was associated with more post-acute care Medicare costs than neurological disorders or renal failure.²

Acute care for the elderly (ACE) programs, which have care specifically tailored to the needs of older patients, have been found to be associated with less functional decline, shorter lengths of stay, fewer adverse events, and lower costs and readmission rates, Dr. Greysen said.

These programs are becoming more common, but they are not spreading as quickly as perhaps they should, he said. In part, this is because of the “know-do” gap, in which practical steps that have been shown to work are not actually implemented because of assumptions that they are already in place or the mistaken belief that simple steps could not possibly make a difference.

Part of the paradigm shift that’s needed, Dr. Greysen said, is an appreciation of the concept of “posthospitalization syndrome,” which is composed of several domains: sleep, function, nutrition, symptom burden such as pain and discomfort, cognition, level of engagement, psychosocial status including emotional stress, and treatment burden including the adverse effects of medications.

Better patient engagement in discharge planning – including asking patients about whether they’ve had help reading hospital discharge–related documents, their level of education, and how often they are getting out of bed – is one necessary step toward change. Surveys of satisfaction using tablets and patient portals is another option, Dr. Greysen said.

The patients of the future will likely prompt their own change, he said, quoting from a 2013 publication.

“Possibly the most promising predictor for change in delivery of care is change in the patients themselves,” the authors wrote. “Baby boomers have redefined the norms at every stage of their lives. ... They will expect providers to engage them in shared decision making, elicit their health care goals and treatment preferences, communicate with providers across sites, and provide needed social supports.”³

 

References

1. Greysen SR et al. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med. 2015 Apr;175(4):559-65.

2. Greysen SR et al. Functional impairment: An unmeasured marker of medicare costs for postacute care of older adults. J Am Geriatr Soc. 2017 Sep;65(9):1996-2002.

3. Laura A. Levit, Erin P. Balogh, Sharyl J. Nass, and Patricia A. Ganz, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. (Washington (DC): National Academies Press (US), 2013 Dec 27).

 

A 57-year-old man is admitted to the hospital with new back pain, which has been getting worse over the past 6 days. He had been diagnosed with stage 4 lung cancer in mid-2017 and underwent treatment with a platinum-based double therapy.

The man also has a history of heroin use – as recently as two years earlier – and he was divorced not long ago. He has been using an old prescription for Vicodin to treat himself, taking as many as 10-12 tablets a day.

This man is an example of the kind of complicated patient hospitalists are called on to treat – complex pain in an era when opioid abuse is considered a public scourge. How is a hospitalist to handle a case like this?

Pain cases are far from the only types of increasingly complex, often palliative cases in which hospitalists are being asked to provide help. Care for the elderly is also becoming increasingly difficult as the U.S. population ages and as hospitalists step in to provide care in the absence of geriatricians. .

Pain management in the opioid era and the need for new approaches in elderly care were highlighted at the Hospital Medicine 2018 annual conference, with experts drawing attention to subtleties that are often overlooked in these sometimes desperate cases.

James Risser, MD, medical director of palliative care at Regions Hospital in Minneapolis, said the complex problems of the 57-year-old man with back pain amounted to an example of “pain’s greatest hits.”

That particular case underscores the need to identify individual types of pain, he said, because they all need to be handled differently. If hospitalists don’t consider all the different aspects of pain, a patient might endure more suffering than necessary.

“All of this pain is swirling around in a very complicated patient,” Dr. Risser said, noting that it is important to “tease out the individual parts” of a complex patient’s history.

“Pain is a very complicated construct, from the physical to the neurological to the emotional,” Dr. Risser said. “Pain is a subjective experience, and the way people interact with their pain really depends not just on physical pain but also their psychological state, their social state, and even their spiritual state.”

Understanding this array of causes has led Dr. Risser to approach the problem of pain from different angles – including perspectives that might not be traditional, he said.

“One of the things that I’ve gotten better at is taking a spiritual history,” he said. “I don’t know if that’s part of everybody’s armamentarium. But if you’re dealing with people who are very, very sick, sometimes that’s the fundamental fabric of how they live and how they die. If there are unresolved issues along those lines, it’s possible they could be experiencing their pain in a different or more severe way.”
 

Varieties of pain

Treatment depends on the pain type, Dr. Risser said. Somatic pain often responds to nonsteroidal anti-inflammatories or steroids.

ah_designs/Getty Images

Neuropathic pain usually responds poorly to anti-inflammatories and to opioids. There is some research suggesting methadone could be helpful, but the data are not very strong. The most common medications prescribed are antiseizure medications and antidepressants, such as gabapentin and serotonin, and norepinephrine reuptake inhibitors.

The question of cancer pain versus noncancer pain can be tricky, Dr. Risser said. If a person’s life expectancy is limited, there can be a reason, or even a requirement, to use higher-risk medications. But, he said, that doesn’t mean the patient still won’t have problems with overuse of pain medication.

“We have a lot of patients now living post cancer who have been put on methadone or have been put on Oxycontin, and now we’re trying to figure out what to do with them,” he said. “I don’t think it’s that clear anymore that there’s a massive difference between cancer and noncancer pain, especially for those survivors.”

Clinicians, he said, should “fix what can be fixed” – and with the right tools. “If you have a patient who’s got severe lower abdominal pain because they have a bladder full or urine, really the treatment would probably not be … opioids. It probably would be a Foley catheter,” he said.

Hospitalists should treat patients based on sound principles of pain management, Dr. Risser said, but “while you try to create a diagnostic framework, know that people continually defy the boxes we put them in.”

Indeed, in an era of pain-medication addiction, it might be a good idea to worry about prescribing opioids, but clinicians have to remember that their goal is to help patients get relief – and that they themselves bring biases to the table, said Amy Davis, DO, MS, of Drexel University, Philadelphia.

In a presentation at HM18, Dr. Davis displayed images of a variety of patients on a large screen – different races and genders, some in business attire, some rougher around the edges.

“Would pain decisions change based on what people look like?” she asked. “Can you really spot who the drug traffickers are? We need to remember that our biases play a huge role not only in the treatment of our patients but in their outcomes. I’m challenging everybody to start thinking about these folks not as drug-seekers but as comfort-seekers.”

When it comes right down to it, she said, patients want a better life, not their drug of choice.

“That is the nature of the disease. [The illegal drug] is not what they’re looking for in reality because that does not provide a good quality of life,” Dr. Davis said. “The [practice of medicine] is supposed to be about helping people live their lives, not just checking off boxes.”

People with an opioid use disorder are physically different, she said. The processing of pain stimuli by their brain and spinal cord is physically altered – they have an increased perception of pain and lower pain tolerance.

“This is not a character flaw,” Dr. Davis affirmed. The increased sensitivity to pain does not resolve with opioid cessation; it can last for decades. Clinicians may need to spend more time interacting with certain patients to get a sense of the physical and nonphysical pain from which they suffer.

“Consistent, open, nonjudgmental communication improves not only the information we gather from patients and families, but it actually changes the adherence,” Dr. Davis said. “Ultimately the treatment outcomes are what all of this is about.”
 

 

Paradigm shift

Another palliative care role that hospitalists often find themselves in is “comforter” of elderly patients.

Dan Burke Photography

Ryan Greysen, MD, MHS, chief of hospital medicine at the University of Pennsylvania, Philadelphia, said hospitals must respond to a shift in the paradigm of elderly care. To explain the nature of this change, he referenced the “paradigm shift” model devised by the philosopher of science Thomas Kuhn, PhD. According to Kuhn, science proceeds in a settled pattern for many years, but on the rare occasions, when there is a fundamental drift in thinking, new problems present themselves and put the old model in a crisis mode, which prompts an intellectual revolution and a shift in the paradigm itself.

“This is a way of thinking about changes in scientific paradigms, but I think it works in clinical practice as well,” Dr. Greysen said.

The need for a paradigm shift in the care of elderly inpatients has largely to do with demographics. By 2050, the number of people aged 65 years and older is expected to be about 80 million, roughly double what it was in 2000. The number of people aged 85 years and up is expected to be about 20 million, or about four times the total in 2000.

In 2010, 40% of the hospitalized population was over 65 years. In 2030, that will flip: Only 40% of inpatients will be under 65 years. This will mean that hospitalists must care for more patients who are older, and the patients themselves will have more complicated medical issues.

“To be ready for the aging century, we must be better able to adapt and address those things that affect seniors,” Dr. Greysen said. With the number of geriatricians falling, much more of this care will fall to hospitalists, he said.

More attention must be paid to the potential harms of hospital-based care to older patients: decreased muscle strength and aerobic capacity, vasomotor instability, lower bone density, poor ventilation, altered thirst and nutrition, and fragile skin, among others, Dr. Greysen said.

In a study published in 2015, Dr. Greysen assessed outcomes for elderly patients who were assessed before hospitalization for functional impairment. The more impaired they were, the more likely they were to be readmitted within 30 days of discharge – from a 13.5% readmission rate for those with no impairment up to 18.2% for those considered to have “dependency” in three or more activities of daily living.¹

In another analysis, severe functional impairment – dependency in at least two activities of daily living – was associated with more post-acute care Medicare costs than neurological disorders or renal failure.²

Acute care for the elderly (ACE) programs, which have care specifically tailored to the needs of older patients, have been found to be associated with less functional decline, shorter lengths of stay, fewer adverse events, and lower costs and readmission rates, Dr. Greysen said.

These programs are becoming more common, but they are not spreading as quickly as perhaps they should, he said. In part, this is because of the “know-do” gap, in which practical steps that have been shown to work are not actually implemented because of assumptions that they are already in place or the mistaken belief that simple steps could not possibly make a difference.

Part of the paradigm shift that’s needed, Dr. Greysen said, is an appreciation of the concept of “posthospitalization syndrome,” which is composed of several domains: sleep, function, nutrition, symptom burden such as pain and discomfort, cognition, level of engagement, psychosocial status including emotional stress, and treatment burden including the adverse effects of medications.

Better patient engagement in discharge planning – including asking patients about whether they’ve had help reading hospital discharge–related documents, their level of education, and how often they are getting out of bed – is one necessary step toward change. Surveys of satisfaction using tablets and patient portals is another option, Dr. Greysen said.

The patients of the future will likely prompt their own change, he said, quoting from a 2013 publication.

“Possibly the most promising predictor for change in delivery of care is change in the patients themselves,” the authors wrote. “Baby boomers have redefined the norms at every stage of their lives. ... They will expect providers to engage them in shared decision making, elicit their health care goals and treatment preferences, communicate with providers across sites, and provide needed social supports.”³

 

References

1. Greysen SR et al. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med. 2015 Apr;175(4):559-65.

2. Greysen SR et al. Functional impairment: An unmeasured marker of medicare costs for postacute care of older adults. J Am Geriatr Soc. 2017 Sep;65(9):1996-2002.

3. Laura A. Levit, Erin P. Balogh, Sharyl J. Nass, and Patricia A. Ganz, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. (Washington (DC): National Academies Press (US), 2013 Dec 27).

 

A 57-year-old man is admitted to the hospital with new back pain, which has been getting worse over the past 6 days. He had been diagnosed with stage 4 lung cancer in mid-2017 and underwent treatment with a platinum-based double therapy.

The man also has a history of heroin use – as recently as two years earlier – and he was divorced not long ago. He has been using an old prescription for Vicodin to treat himself, taking as many as 10-12 tablets a day.

This man is an example of the kind of complicated patient hospitalists are called on to treat – complex pain in an era when opioid abuse is considered a public scourge. How is a hospitalist to handle a case like this?

Pain cases are far from the only types of increasingly complex, often palliative cases in which hospitalists are being asked to provide help. Care for the elderly is also becoming increasingly difficult as the U.S. population ages and as hospitalists step in to provide care in the absence of geriatricians. .

Pain management in the opioid era and the need for new approaches in elderly care were highlighted at the Hospital Medicine 2018 annual conference, with experts drawing attention to subtleties that are often overlooked in these sometimes desperate cases.

James Risser, MD, medical director of palliative care at Regions Hospital in Minneapolis, said the complex problems of the 57-year-old man with back pain amounted to an example of “pain’s greatest hits.”

That particular case underscores the need to identify individual types of pain, he said, because they all need to be handled differently. If hospitalists don’t consider all the different aspects of pain, a patient might endure more suffering than necessary.

“All of this pain is swirling around in a very complicated patient,” Dr. Risser said, noting that it is important to “tease out the individual parts” of a complex patient’s history.

“Pain is a very complicated construct, from the physical to the neurological to the emotional,” Dr. Risser said. “Pain is a subjective experience, and the way people interact with their pain really depends not just on physical pain but also their psychological state, their social state, and even their spiritual state.”

Understanding this array of causes has led Dr. Risser to approach the problem of pain from different angles – including perspectives that might not be traditional, he said.

“One of the things that I’ve gotten better at is taking a spiritual history,” he said. “I don’t know if that’s part of everybody’s armamentarium. But if you’re dealing with people who are very, very sick, sometimes that’s the fundamental fabric of how they live and how they die. If there are unresolved issues along those lines, it’s possible they could be experiencing their pain in a different or more severe way.”
 

Varieties of pain

Treatment depends on the pain type, Dr. Risser said. Somatic pain often responds to nonsteroidal anti-inflammatories or steroids.

ah_designs/Getty Images

Neuropathic pain usually responds poorly to anti-inflammatories and to opioids. There is some research suggesting methadone could be helpful, but the data are not very strong. The most common medications prescribed are antiseizure medications and antidepressants, such as gabapentin and serotonin, and norepinephrine reuptake inhibitors.

The question of cancer pain versus noncancer pain can be tricky, Dr. Risser said. If a person’s life expectancy is limited, there can be a reason, or even a requirement, to use higher-risk medications. But, he said, that doesn’t mean the patient still won’t have problems with overuse of pain medication.

“We have a lot of patients now living post cancer who have been put on methadone or have been put on Oxycontin, and now we’re trying to figure out what to do with them,” he said. “I don’t think it’s that clear anymore that there’s a massive difference between cancer and noncancer pain, especially for those survivors.”

Clinicians, he said, should “fix what can be fixed” – and with the right tools. “If you have a patient who’s got severe lower abdominal pain because they have a bladder full or urine, really the treatment would probably not be … opioids. It probably would be a Foley catheter,” he said.

Hospitalists should treat patients based on sound principles of pain management, Dr. Risser said, but “while you try to create a diagnostic framework, know that people continually defy the boxes we put them in.”

Indeed, in an era of pain-medication addiction, it might be a good idea to worry about prescribing opioids, but clinicians have to remember that their goal is to help patients get relief – and that they themselves bring biases to the table, said Amy Davis, DO, MS, of Drexel University, Philadelphia.

In a presentation at HM18, Dr. Davis displayed images of a variety of patients on a large screen – different races and genders, some in business attire, some rougher around the edges.

“Would pain decisions change based on what people look like?” she asked. “Can you really spot who the drug traffickers are? We need to remember that our biases play a huge role not only in the treatment of our patients but in their outcomes. I’m challenging everybody to start thinking about these folks not as drug-seekers but as comfort-seekers.”

When it comes right down to it, she said, patients want a better life, not their drug of choice.

“That is the nature of the disease. [The illegal drug] is not what they’re looking for in reality because that does not provide a good quality of life,” Dr. Davis said. “The [practice of medicine] is supposed to be about helping people live their lives, not just checking off boxes.”

People with an opioid use disorder are physically different, she said. The processing of pain stimuli by their brain and spinal cord is physically altered – they have an increased perception of pain and lower pain tolerance.

“This is not a character flaw,” Dr. Davis affirmed. The increased sensitivity to pain does not resolve with opioid cessation; it can last for decades. Clinicians may need to spend more time interacting with certain patients to get a sense of the physical and nonphysical pain from which they suffer.

“Consistent, open, nonjudgmental communication improves not only the information we gather from patients and families, but it actually changes the adherence,” Dr. Davis said. “Ultimately the treatment outcomes are what all of this is about.”
 

 

Paradigm shift

Another palliative care role that hospitalists often find themselves in is “comforter” of elderly patients.

Dan Burke Photography

Ryan Greysen, MD, MHS, chief of hospital medicine at the University of Pennsylvania, Philadelphia, said hospitals must respond to a shift in the paradigm of elderly care. To explain the nature of this change, he referenced the “paradigm shift” model devised by the philosopher of science Thomas Kuhn, PhD. According to Kuhn, science proceeds in a settled pattern for many years, but on the rare occasions, when there is a fundamental drift in thinking, new problems present themselves and put the old model in a crisis mode, which prompts an intellectual revolution and a shift in the paradigm itself.

“This is a way of thinking about changes in scientific paradigms, but I think it works in clinical practice as well,” Dr. Greysen said.

The need for a paradigm shift in the care of elderly inpatients has largely to do with demographics. By 2050, the number of people aged 65 years and older is expected to be about 80 million, roughly double what it was in 2000. The number of people aged 85 years and up is expected to be about 20 million, or about four times the total in 2000.

In 2010, 40% of the hospitalized population was over 65 years. In 2030, that will flip: Only 40% of inpatients will be under 65 years. This will mean that hospitalists must care for more patients who are older, and the patients themselves will have more complicated medical issues.

“To be ready for the aging century, we must be better able to adapt and address those things that affect seniors,” Dr. Greysen said. With the number of geriatricians falling, much more of this care will fall to hospitalists, he said.

More attention must be paid to the potential harms of hospital-based care to older patients: decreased muscle strength and aerobic capacity, vasomotor instability, lower bone density, poor ventilation, altered thirst and nutrition, and fragile skin, among others, Dr. Greysen said.

In a study published in 2015, Dr. Greysen assessed outcomes for elderly patients who were assessed before hospitalization for functional impairment. The more impaired they were, the more likely they were to be readmitted within 30 days of discharge – from a 13.5% readmission rate for those with no impairment up to 18.2% for those considered to have “dependency” in three or more activities of daily living.¹

In another analysis, severe functional impairment – dependency in at least two activities of daily living – was associated with more post-acute care Medicare costs than neurological disorders or renal failure.²

Acute care for the elderly (ACE) programs, which have care specifically tailored to the needs of older patients, have been found to be associated with less functional decline, shorter lengths of stay, fewer adverse events, and lower costs and readmission rates, Dr. Greysen said.

These programs are becoming more common, but they are not spreading as quickly as perhaps they should, he said. In part, this is because of the “know-do” gap, in which practical steps that have been shown to work are not actually implemented because of assumptions that they are already in place or the mistaken belief that simple steps could not possibly make a difference.

Part of the paradigm shift that’s needed, Dr. Greysen said, is an appreciation of the concept of “posthospitalization syndrome,” which is composed of several domains: sleep, function, nutrition, symptom burden such as pain and discomfort, cognition, level of engagement, psychosocial status including emotional stress, and treatment burden including the adverse effects of medications.

Better patient engagement in discharge planning – including asking patients about whether they’ve had help reading hospital discharge–related documents, their level of education, and how often they are getting out of bed – is one necessary step toward change. Surveys of satisfaction using tablets and patient portals is another option, Dr. Greysen said.

The patients of the future will likely prompt their own change, he said, quoting from a 2013 publication.

“Possibly the most promising predictor for change in delivery of care is change in the patients themselves,” the authors wrote. “Baby boomers have redefined the norms at every stage of their lives. ... They will expect providers to engage them in shared decision making, elicit their health care goals and treatment preferences, communicate with providers across sites, and provide needed social supports.”³

 

References

1. Greysen SR et al. Functional impairment and hospital readmission in medicare seniors. JAMA Intern Med. 2015 Apr;175(4):559-65.

2. Greysen SR et al. Functional impairment: An unmeasured marker of medicare costs for postacute care of older adults. J Am Geriatr Soc. 2017 Sep;65(9):1996-2002.

3. Laura A. Levit, Erin P. Balogh, Sharyl J. Nass, and Patricia A. Ganz, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. (Washington (DC): National Academies Press (US), 2013 Dec 27).