Month: September 2011

Main Category: Alzheimer’s / Dementia
Also Included In: Seniors / Aging;  Palliative Care / Hospice Care;  Medicare / Medicaid / SCHIP
Article Date: 30 Sep 2011 – 0:00 PDT

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A new study in the Sept. 29, 2011, edition of the New England Journal of Medicine reports that nearly one in five nursing home residents with advanced dementia experiences burdensome transitions in the last 90 days of life, such as moving to a different facility in the last three days of life or repeat hospitalizations for expected complications of dementia in the last 90 days of life.

“Such patterns of transitions are burdensome, particularly since the overwhelming majority of family members state the main goal of care is comfort,” said study co-author Joan Teno, professor of health policy and practice at the Warren Alpert Medical School of Brown University and a palliative care physician. “These transitions reflect the inefficiency of our health care system. Similar outcomes could be achieved by keeping these patients in the nursing home setting.”

An important reason for the prevalence of burdensome transitions might be embedded in the way Medicare pays nursing homes, said Brown health economist and lead author Pedro Gozalo. Nursing homes can earn higher payments for patients who have been transferred to a hospital for three days and they may qualify for skilled nursing services paid by Medicare rather than Medicaid upon their return. The current incentives under Medicare and Medicaid encourage nursing homes to send patients to the hospital, he said.

What makes the transitions burdensome, especially for patients with cognitive impairment, Teno said, is that they are often unnecessary, raise the risk of medical errors, and interrupt continuity of care for patients who can experience significant stress and disorientation when they are suddenly removed from familiar surroundings and people. When the patients become upset, their families experience more stress.

Because these financial incentives, market conditions, and the culture of end-of-life care vary by state, so do the rates of burdensome transitions. The authors, who also include researchers from Harvard University and Dartmouth College, found that the overall percentage of patients experiencing at least one burdensome transition was 19 percent. State-level rates varied from 2.1 percent in Alaska to 37.5 percent in Louisiana.

“These burdensome transitions are not only bad for the patient, they also drain the federal treasury, hastening the day when the Medicare trust fund runs out of money,” said economist Jonathan Skinner from Dartmouth College, a co-author on the study.

Blacks and Hispanics were also more likely than whites to experience burdensome transitions, the authors found.

Amiss before dying

To reach these conclusions, the team analyzed federal databases of nursing home and Medicare records accumulated between 2000 and 2007. In all, they found 474,829 patients who were older than 66, had advanced cognitive impairment, and lived in a nursing home 120 days before their death. Of these, 90,228 residents experienced at least one burdensome transition, defined as either a transfer in the last three days of life, returning to a different nursing home than the one they lived in before they went to the hospital, or multiple hospitalizations in the last 90 days of life.

Often these hospitalizations occur even though the condition prompting the hospitalization – pneumonia, urinary tract infection, or dehydration – could easily be treated in a properly equipped and staffed nursing home.

These variations were particularly wide across different geographic areas. In McAllen, Texas, 25.8 percent of patients had multiple hospitalizations for urinary tract infections, pneumonia or dehydration, compared to only 1.1 percent of patients in Grand Junction, Colo.

The regional rate of burdensome transitions also correlates with other indicators of poor end-of-life care, Gozalo noted. Compared to patients living in the health care markets with the lowest rates of burdensome transitions, those who lived in the regions with the highest rates were three times more likely to have a feeding tube inserted, more than twice as likely to be in the intensive care unit in the last 30 days of life, and more than twice as likely to have developed an advanced pressure ulcer.

Ultimately, Teno said, all of these problems are signs of care gone awry. The best care for a patient with advanced cognitive impairment near the end of life is often to maximize comfort. The burdens of hospitalization usually outweigh the benefits.

“Our research calls for efforts to reform health care payment that create incentives to improve advance care planning and care coordination,” Gozalo said. “Current reform efforts like accountable care organizations that bundle both the hospital and post-acute care payments could begin to address some of these perverse incentives. We need financial incentives to make sure that people are getting the right care in the right place at the right time.”

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Main Category: Prostate / Prostate Cancer
Also Included In: Medicare / Medicaid / SCHIP
Article Date: 25 Sep 2011 – 0:00 PDT

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In a study of complication rates following prostate biopsy among Medicare beneficiaries, Johns Hopkins researchers have found a significant rise in serious complications requiring hospitalization. The researchers found that this common outpatient procedure, used to diagnose prostate cancer, was associated with a 6.9 percent rate of hospitalization within 30 days of biopsy compared to a 2.9 percent hospitalization rate among a control group of men who did not have a prostate biopsy. The study, which will be published in the November 2011 issue of The Journal of Urology, was posted early online.

The researchers emphasize that this new data should serve as a reminder to physicians to carefully weigh the risks and benefits of biopsy for individual patients and take all precautions to prevent infections and other complications.

The Johns Hopkins team’s findings are the result of the largest analysis ever performed of Medicare records of American men age 65 and older who underwent prostate biopsies in the last two decades. They found that having a prostate biopsy makes patients more than twice as likely to need hospitalization in the immediate post-procedure period. Those hospitalized had a range of complications, such as bleeding and infection, as well as flare-ups of underlying medical conditions, such as heart failure or breathing disorders.

Overall, mortality rates in men undergoing prostate biopsies did not increase. However, men hospitalized with biopsy-related infections had a 12-fold higher risk of death compared to men who did not have a biopsy.

“Prostate biopsy is an essential procedure for detecting prostate cancers,” says Edward Schaeffer, M.D., Ph.D., a Johns Hopkins urologist and oncologist and the study’s senior investigator. “Coupled with appropriate screening, prostate biopsies save lives. However, it is important for men to be aware of the possible risks of prostate biopsies, which are often described as simple outpatient procedures,” adds Schaeffer, an associate professor at the Johns Hopkins University School of Medicine and its Brady Urological Institute.

In their study, the researchers examined the frequency of biopsy related complications that required hospitalization in more than 17,400 men age 65 and older from 1991 to 2007. They compared these rates to a cohort of 134,977 men during the same time period with similar characteristics who did not undergo a prostate biopsy. The researchers only looked at hospital admissions, not men whose complications were treated in an emergency department or outpatient setting.

While the rate of hospitalization following prostate biopsy has declined steadily since 1991, the researchers found that the rate of hospitalization during the time period was still two-fold higher among the men who had a biopsy (6.9 percent compared to 2.9 percent).

There was also a steady rise in the rate of serious infection-related complications. At the onset of the study in 1991, fewer than 0.5 percent of men were admitted to the hospital because of an infection diagnosed following a prostate biopsy. This rate remained stable until 2000, when rates of infection-related complications began to increase to more than 1.2 percent in 2007.

“Antibiotics are routinely given to men at the time of biopsy, and the fact that infections serious enough to cause hospital admissions have been on the rise makes us think that these types of complications are occurring because of a steady increase in antimicrobial resistance rates in America,” says Schaeffer.

Co-author H. Ballentine Carter, M.D., professor of urology and oncology at the Johns Hopkins University School of Medicine, says, “Based on these findings, we believe that more needs to be done to reduce potential complications. It is important for urologists to determine if a biopsy is appropriate for an individual patient and also if the patient is at increased risk for a biopsy- related complication.”

The researchers say that prostate biopsies should only be performed with strict adherence to medical guidelines, and after all potential risks and benefits have been reviewed with patients. More than 1 million prostate biopsy procedures are performed each year in the United States to diagnose and monitor prostate cancer, which is the second most common cause of cancer death among men.

Funding for the study was provided by the Howard Hughes Medical Institute, the U.S. National Institutes of Health, an American Urological Association Astellas Research Star Award, and the Patrick C. Walsh Prostate Cancer Research Fund at Johns Hopkins.

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