When it comes to high blood pressure treatment in the elderly, the plot continues to thicken.
Last December, a minor controversy erupted when the JNC hypertension guidelines proposed a higher blood pressure (BP) treatment target (150/90) for adults aged 60+.
And now this month, a study in JAMA Internal Medicine reports that over 3 years, among a cohort of 4961 community-dwelling Medicare patients aged 70+ and diagnosed with hypertension, those on blood pressure medication had more serious falls.
Serious falls as in: emergency room visits or hospitalizations for fall-related fracture, brain injury, or dislocation of the hip, knee, shoulder, or jaw. In other words, we talking about real injuries and real patient suffering. (As well as real healthcare utilization, for those who care about such things.)
How many more serious falls are we talking? The study cohort was divided into three groups: no antihypertensive medication (14.1%), moderate intensity treatment (54.6%), and high-intensity treatment (31.3%).
Over the three year follow-up period, a serious fall injury happened to 7.5% of those in the no-antihypertensive group, 9.8% of the moderate-intensity group, and 8.2% of the high-intensity group. In a propensity-matched subcohort, serious falls happened to 7.1% of the no-treatment group, 8.6% of the moderate-intensity group, and 8.5% of the high-intensity group. (Propensity-matching is a technique meant to adjust for confounders – such as overall illness burden — between the three groups.)
The methodologists in the audience should certainly read the paper in detail and go find things to pick apart. For the rest of us, what are the practical take-aways?
Continue reading “Clinic: A Cautionary Note About the Risks of Blood Pressure Treatment in the Elderly”
Filed Under: THCB
Tagged: Blood Pressure, Geriatrics, Leslie Kernisan, Telemonitoring, Wellness
Feb 28, 2014
When it comes to the health care of a frail older person, families really need a good personal health record (PHR) system. So I am once again preparing to take a look at what’s available, in hopes of finding something that I can more confidently recommend to the families I work with. (To see what medical info I urge families to track, see this Geriatrics for Caregivers post.)
I have — yet again — met a family with reams of paper health records. On one hand, they’ve done very well: at our first visit they were able to show me labs, MRI results, and even some specialty consultations from last summer. They even had a hospital discharge summary, although unfortunately not the one from the most recent hospitalization.
And they’d taken steps to digitally organize, having scanned several key items, as well as created an online space providing shared access to their parent’s information.
So this is better than the situation I often encounter, which is that an elderly person has seen multiple outpatient doctors, has been hospitalized in a few different facilities, and no one has a copy of anything handy. (See why new elderly patients are a killer in primary care? If there is no data you fly blind, if there IS data it can take hours to review it.)
Still, there are clearly many ways a little well-designed technology could improve things for this family – and for the doctors trying to help them.
Here are the problems we have right now:
- Hard to search the whole pile, whether on paper or via the family’s online repository of PDFs. These were not OCRed and searchable until I manually converted them with my own PDF editor, after which I had to upload them to the patient’s chart in my EMR. Now each file is text searchable (for me), but the pile still is not.
- Cannot trend the labs. Figuring out what has happened to this patient’s key lab values over the past year has been very labor-intensive. This remains a problem once the lab data is uploaded to my EMR, because it’s still in PDFs which have to be looked at one at a time. Being the nerdy doc that I am, I’ve spent a fair bit of time creating a note that summarizes the key lab data over time. Ugh. Better than nothing but a far cry from being able to graph and trend the patient’s labs as needed.
- Takes ongoing time and effort to get records from the hospitals and other involved doctors. Kudos to this family for being diligent and persistent in asking for copies of everything they can. But wow, it’s a lot of effort for them, and I can tell you that in my practice so far, I’ve generally had to expend a fair amount of energy repeatedly asking for information from other providers. (And then I’ve had to try to organize all this info which comes in as scanned images via fax. Oy!)
Continue reading “In Search of a Really Usable PHR”
Filed Under: Tech, THCB
Tagged: caregivers, Design, FutureMed, Geriatrics, health records, Leslie Kernisan, PHRs
Jan 11, 2014
Last month an intriguing new decision support app launched, created by experts in geriatrics and palliative care. It’s meant to help with an important primary care issue: cancer screening in older adults.
Have you ever asked yourself, when considering cancer screening for an older adult, whether the likely harms outweigh the likely benefits?
Maybe you have, maybe you haven’t. The sentence above, after all, is a bit of wonky formulation for the following underlying questions:
- How long is this person likely to live, given age and health situation?
- Given this person’s prognosis, does cancer screening make sense?
The first question seems like one that could easily occur to a person — whether that be a patient, a family member, or a clinician – although I suspect it doesn’t occur to people perhaps as often as it should.
As for the second question, I’m not sure how often it pops up in people’s minds, although it’s certainly very important to consider, given what we now know about the frequent harms of cancer screening in the elderly, and usually less frequent benefits.
Furthermore, there is abundant evidence that “inappropriate” cancer screening remains common. “Inappropriate” meaning the screening of people who are so unwell and/or old that they’re unlikely to live long enough to benefit from screening.
For instance, one astounding study found that 25% of physicians said they’d order colon cancer screening for an 80 year old with inoperable lung cancer. So it’s clear that improving the decision-making around cancer screening would help improve healthcare safety, quality, and value.
Continue reading “The ePrognosis App: How Calculating Life Expectancy Can Influence Healthcare Decision-Making”
Filed Under: Tech, THCB
Tagged: ePrognosis, Geriatrics, Leslie Kernisan, Screening
Nov 22, 2013
A few weeks ago, I went for the first time to Stanford’s Medicine X conference. It’s billed as a conference that brings a “broad, academic approach to understanding emerging technologies with the potential to improve health and advance the practice of medicine.”
Well, I went, I saw, and I even briefly presented (in a workshop on using patient-generated data).
And I am now writing to tell you about the most important innovations that I learned about at Medicine X (MedX).
They were not the new digital health technologies, even though we heard about many interesting new tools, systems, and apps at the conference, and I do believe that leveraging technology will result in remarkable changes in healthcare.
Nor were they related to social media, ehealth, or telehealth, even though all of these are rapidly growing and evolving, and will surely play important roles in the healthcare landscape of the future.
No. The most remarkable innovations at MedX related to the conference itself, which was unlike any other academic conference I’ve been to. Specifically, the most important innovations were:
- Patients present to tell their stories, both on stage and in more casual conversational settings such as meals.
- Patient participation in brainstorming healthcare solutions and in presenting new technologies. MedX also has an ePatient Advisors group to help with the overall conference planning.
These innovations, along with frequent use of storytelling techniques, video, and music, packed a powerful punch. It all kept me feeling engaged and inspired during the event, and left me wishing that more academic conferences were like this.
These innovations point the way to much better academic conferences. Here’s why:
The power of patient presence
I wasn’t surprised to see lots of patients at Medicine X, because I knew that the conference has an e-patient scholars program, and that many patients would be presenting. I also knew that the director of MedX, Dr. Larry Chu, is a member of the Society of Participatory Medicine. (Disclosure: I’ve been a member of SPM since last December.)
I was, on the other hand, surprised by how powerful it was to have patients on stage telling their stories.
How could it make such a difference? I am, after all, a practicing physician who spends a lot of time thinking about the healthcare experience of older adults and their caregivers.
But it did make a difference. I found myself feeling more empathetic, and focused on the patient and family perspective. And I felt more inspired to do better as a physician and as a healthcare problem-solver.
In short, having patients tell their stories helped me engage with the conference presentations in a more attentive and meaningful way.
Now, some will surely be tempted to wave this off as a gauzy touchy-feely experience that is peculiar to the fruit-cakes of the Bay Area; a nice conference touch that isn’t materially important to the purpose of an academic conference.
Continue reading “* Patients Not Included”
Filed Under: Physicians, Tech, THCB
Tagged: digital health, e-patients, Leslie Kernisan, patient engagement, Patients, Stanford Medicine X, Tech
Oct 25, 2013
I recently attended the flagship Health 2.0 conference for the first time.
To avoid driving in traffic, I commuted via Caltrain, and while commuting, I read Katy Butler’s book “Knocking on Heaven’s Door.”
Brief synopsis: healthy active well-educated older parents, father suddenly suffers serious stroke, goes on to live another six years of progressive decline and dementia, life likely extended by cardiologist putting in pacemaker, spouse and daughter struggle with caregiving and perversities of healthcare system, how can we do better? See original NYT magazine article here.
(Although the book is subtitled “The Path to a Better Way of Death,” it’s definitely not just about dying. It’s about the fuzzy years leading up to dying, which generally don’t feel like a definite end-of-life situation to the families and clinicians involved.)
The contrast between the world in the book — an eloquent description of the health, life, and healthcare struggles that most older adults eventually endure — and the world of Health 2.0′s innovations and solutions was a bit striking.
I found myself walking around the conference, thinking “How would this help a family like the Butlers? How would this help their clinicians better meet their needs?”
The answer, generally, was unclear. At Health 2.0, as at many digital health events, there is a strong bias toward things like wellness, healthy lifestyles, prevention, big data analytics, and making patients the CEOs of their own health.
Oh and, there was also the Nokia XPrize Sensing Challenge, because making biochemical diagnostics cheap, mobile, and available to consumers is not only going to change the world, but according to the XPrize rep I spoke to, it will solve many of the problems I currently have in caring for frail elders and their families.
(In truth it would be nice if I could check certain labs easily during a housecall, and the global health implications are huge. But enabling more biochemical measurements on my aging patients is not super high on my priority list.)
Continue reading “Knocking on Health 2.0′s Door”
Filed Under: Tech, THCB
Tagged: caregivers, digital health, End of Life Care, Entrepreneurs, Geriatrics, Health 2.0, Health 2.0 Fall 2013 Conference, Knocking on Heaven's Door, Leslie Kernisan, Tech
Oct 16, 2013
I assume by now that you’ve heard the news: Google wants to tackle aging. Specifically, they announced this week the launch of Calico, “a new company that will focus on health and well-being, in particular the challenge of aging and associated diseases.”
Because, says Larry Page, with some “moonshot thinking around healthcare and biotechnology, I believe we can improve millions of lives.”
“Can Google Solve DEATH?” shrieks a TIME cover.
Google’s goal, it seems is to find ways to extend human lifespan and essentially stave off aging.
Coincidentally, on the same day Physician’s First Watch directed me towards this NEJM editorial, announcing that NEJM and the Harvard Business Review are teaming up on a project on Leading Health Care Innovation.
Here is the paragraph that particularly caught my eye:
“The health care community and the business community today share a fundamental interest in finding ways to achieve higher value in health care. The ultimate objective for both communities is to keep people healthy, prevent the chronic illnesses that consume a large fraction of our health care dollars, use medical interventions appropriately and only when needed, and create an economically sustainable approach to the delivery of health care. While we want to foster innovation and novel therapies against disease, we also recognize that, whenever possible, prevention of disease before it is established is the better solution.” [Emphasis mine.]
And therein lies the rub. Whether it’s Google or a high-powered partnership between NEJM & HBR, everyone is enamored of prevention and innovative cures.
Let’s prevent those pesky chronic diseases! Let’s cure aging!
Ah, spare me.
Continue reading “Who Will Solve Healthcare For Our Parents And Grandparents? Probably Not Google.”
Filed Under: OP-ED, THCB
Tagged: aging, Calico, Caregiving, Geriatrics, Google, Innovation, Leslie Kernisan, prevention
Sep 25, 2013
The developers of the app Pain Care, the winner of the Robert Wood Johnson Foundation’s Project Health Design challenge two years ago, have this to say about THCB contributing writer Dr. Leslie Kernisan’s recent post wondering why the winning entries of development challenges have a habit of disappearing and never being heard from again:
We are the app developer. We are also disappointed with the outcome of the app. But I think we also learned valuable lessons here.
One of the challenges small business facing is the need to rapid prototype and test the market, and then move on to another idea when the previous idea fails to gain traction. That is especially true with grant funded projects — they need to “make money” after the grant ends in order to justify continued development effort.
Pain Care was developed in the early days of mHealth, and it was indeed very physician focused — the reason is that we believe we must engage physicians to look at the data. We still hold that belief. It is a learning process for us. We put in our own money to develop the app, and fortunately, won the developer challenge.
We made the app public after the challenge to “test the market” — so to speak. But, as you know, essentially *none* of the pure app-based “patient journal” has turned out to be a success (let alone a financial success). Our app is no exception. It is enormously costly keep the app updated for all those iPhone, iPad, iOS released every year, as well as thousands of Android devices released since then.
So, the app becomes one of those “outdated” apps in the app store, and I think it is quite obvious to users as well. However, I think the app did contribute significantly to the “science” of mHealth. We now understand much more what works and what not in “patient engagement”. Many other “pain management” apps have since emerged, and many have done a better job than ours. I think that was what RWJF wanted when they challenged developers back then.
Today, we do things a lot differently. We no longer release research grant-funded apps to the public. Instead, we run clinical studies to test them in much smaller / controlled groups. We do not attempt to tackle vague “big problems” like general pain management any more — instead, we are much more focused on managing specific diseases that include pain. We are also moving beyond “pure software” and “simple reminders” to engage people in multiple modalities.
All of these would not be possible without the generous award RWJF gave us in picking Pain Care as the winner of one of the first developer challenges.
Filed Under: Tech, THCB
Tagged: Apps, Commentology, Leslie Kernisan, mHealth, Pain Care, RWJF
Sep 24, 2013
What is patient engagement?
Everyone agrees that it’s a good thing, and that we healthcare providers should be fostering it.
How to do so, however, depends on just what you believe patient engagement means.
As Dan Munro recently pointed out, the term “patient engagement” is a hot buzz phrase, and – in the best tradition of such phrases – it’s amorphous enough and appealing enough to mean…just about anything.
Provided that it that makes us feel good about healthcare, of course. Better yet, provided that it casts our favorite healthcare approaches in a favorable light. (Rob Lamberts nicely summarizes some angles of the term here.)
I actually rather liked Munro’s post, titled “Patient engagement: Blockbuster Drug or Snake Oil?” until he got to this part: “We now have some very real metrics around what constitutes real patient engagement and Leonard highlighted two impressive examples.” He goes on to point to two studies of care coordination for chronic illness — one at Kaiser and the other at the VA – and summarizes some key improvements in outcomes.
At Kaiser, they included things like decreased mortality rates and fewer emergencies, as well as improved cholesterol screenings and more people meeting cholesterol goals. With the VA’s Telehealth program, hospital days were reduced and patient satisfaction was 86%. (BTW, I had a VA primary care clinic from 2006-2010, and several of my patients were in Telehealth.)
These are indeed nice results. Still, somehow they didn’t impress me as constituting “real patient engagement.” They seemed more like “real population health management, facilitated by teams, care coordination, communication infrastructure, and organized protocols.”
Shouldn’t real patient engagement mean more than this?
Defining patient engagement
Here’s my current take:
Supporting patient engagement means fostering a fruitful collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.
Continue reading “Patient Engagement: On Metrics and Meaning”
Filed Under: OP-ED, THCB
Tagged: doctor/ patient relationship, Leslie Kernisan, patient engagement, shared decision making
Sep 12, 2013
What does it mean when an app wins a major foundation’s developer challenge, and then isn’t updated for two and a half years?
Today, as I was doing a little background research on task management apps for caregivers, I came across a 2012 post listing Pain Care as a handy app for caregivers.
Pain is certainly something that comes up a lot when it comes to geriatrics and supporting caregivers, so I decided to learn a little more about this app.
“The Pain Care app won the “Project HealthDesign” challenge by the Robert Wood Johnson Foundation and California HealthCare Foundation,” reads the descriptive text in the Google Play Store.
Well, well, well! RWJF and CHCF are big respectable players in my world, so I was impressed.
But then as I looked at the user reviews, I noticed something odd. Namely, that the most recent one seems to be from April 2012, which is like 2-3 generations ago when it comes to apps.
And furthermore, the app itself was last updated in February 2011. This is like a lifetime ago when it comes to apps.
I decided to download the app and give it a whirl. It’s ok. Seems to be an app for journaling and documenting pain episodes, along with associated triggers. Really looks like something developed by doctors: one of the options for describing the type of pain is “lancinating,” and in a list of “side-effects” (side effects of what? the pain medication one may have just taken?) there is the option to check “sexual dysfunction.” Or you could check “Difficulty with breathing.” (In case you just overdosed on your opiates, perhaps.)
The app does connect to a browser-based account where I was able to view a summary of the pain episode I’d documented. It looked like something that one should print and give to a doctor, and in truth, it would probably be helpful.
Setting snarky comments about the vocabulary aside: this app actually looks like a good start for a pain journal. But it needs improvement and refining, in order to improve usability and quality. Also, although I don’t know much about app development and maintenance, I assume that apps should be periodically upgraded to maintain good performance as the operating systems of iPhones and Android phones evolve.
Continue reading “When Foundation-Approved Apps Founder”
Filed Under: Tech, THCB
Tagged: Apps, caregivers, Leslie Kernisan, mHealth, Pain Care, Project HealthDesign, RWJF
Sep 6, 2013
Why aren’t people in hospitals more attentive to the needs of patients?
In a recent post, Dr. Ashish Jha raises this issue as he relates his own story of coming to an ED with a very painful dislocated shoulder. Unsurprisingly, prompt treatment of his pain was deferred while staff diligently completed registration, sent him for an xray, and waited for a physician to see him.
On the bike path where Jha took his initial tumble, people went out of their way to respond to his injury with attention and concern. But as he lay moaning on a gurney in the hospital corridors, waiting for an xray and not yet treated for pain, people avoided his eyes and even walked by a little faster.
What gives? Why aren’t people in the hospital more empathetic and attentive? Is this a “wonderful people, bad system” issue?
In reflecting on his experience, Jha remarks that people seem to leave their humanity at the door when they arrive at the hospital for work, and posits that we get desensitized to suffering. He notes that some workers were able to “break out of that trap,” and responded to him more empathetically when he directly solicited their help and attention.
“It is the job of healthcare leaders to create a culture where we retain our humanity despite the constant exposure to patients who are suffering,” writes Jha.
Culture change is necessary but not sufficient
Culture is important. Yes I’ll admit that I’m usually a bit skeptical when I hear of a plan to tackle a problem through culture change. In my own experience, this has consisted of leaders trying to “create culture” by describing to front-line staff what they should be doing, and repeatedly exhorting them to do it. (And maybe giving out gold stars to those who do it.)
This, of course, is never enough. Talking the talk does not mean people start to walk the walk, especially if the walk involves a slog uphill rather than an easier stroll down a path of lesser resistance.
If we – whether healthcare leaders or just concerned citizens who want to see healthcare improve – really want healthcare workers to demonstrate more compassion and empathy while on the job, then here is what we need to do:
- We should take seriously the task of understanding what might be interfering with this compassion and engagement. This means not only studying workflow, but also the behavioral psychology of individuals as well as groups.
- We should then be serious about creating the conditions that would allow regular human beings to reliably produce the desired behaviors.
Why it can be hard to help people in the hospital
What interferes with showing compassion and engagement? In reading Jha’s piece, I reflected on my own hospital days. Here are the obstacles that I remember, and the impact on me.
Continue reading “Creating Conditions for Humanity in Hospitals”
Filed Under: Physicians, THCB
Tagged: caregivers, culture of healthcare, emergency room visit, Hospitals, Leslie Kernisan, patient engagement, Patient Safety
Aug 25, 2013