Effectiveness of geriatric specialists, leading to a brief discussion of the “separate accounts” fallacy in decision making and a comparison of the climates of Baltimore and St. Paul

I’d like to move from basketball to something more important: geriatric care, a topic I was reminded of after reading this interesting article by Atul Gawande.

The article starts with some general discussion of the science of human aging, then moves to consider options for clinical treatment. Gawande learns a lot from observing a gerontologist’s half-hour meeting with a patient. He tells a great story (too long to make sense to repeat here), although I suspect he was choosing the best out of the many patients he observed. He notes:

In the story of Jean Gavrilles and her geriatrician, there’s a lesson about frailty. Decline remains our fate; death will come. But, until that last backup system inside each of us fails, decline can occur in two ways. One is early and precipitately, with an old age of enfeeblement and dependence, sustained primarily by nursing homes and hospitals. The other way is more gradual, preserving, for as long as possible, your ability to control your own life.

Good medical care can influence which direction a person’s old age will take. Most of us in medicine, however, don’t know how to think about decline. We’re good at addressing specific, individual problems: colon cancer, high blood pressure, arthritic knees. Give us a disease, and we can do something about it. But give us an elderly woman with colon cancer, high blood pressure, arthritic knees, and various other ailments besides—an elderly woman at risk of losing the life she enjoys—and we are not sure what to do.

Gawande continues with a summary of this study:

Several years ago, researchers in St. Paul, Minnesota, identified five hundred and sixty-eight men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric specialists. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, ten per cent of the patients in both groups had died. But the patients who had seen a geriatrics team were a third less likely to become disabled and half as likely to develop depression. They were forty per cent less likely to require home health services.

Little of what the geriatricians had done was high-tech medicine: they didn’t do lung biopsies or back surgery or PET scans. Instead, they simplified medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

But now comes the kicker:

How do we reward this kind of work? Chad Boult, who was the lead investigator of the St. Paul study and a geriatrician at the University of Minnesota, can tell you. A few months after he published his study, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.

“The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he is now a professor at the Johns Hopkins Bloomberg School of Public Health.

One of the problems comes from the “separate accounts” fallacy in decision making:

On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a twenty-five-thousand-dollar pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs. Scores of medical centers across the country have shrunk or closed their geriatrics units. Several of Boult’s colleagues no longer advertise their geriatric training for fear that they’ll get too many elderly patients. “Economically, it has become too difficult,” Boult said.

But the finances are only a symptom of a deeper reality: people have not insisted on a change in priorities. We all like new medical gizmos and demand that policymakers make sure they are paid for. They feed our hope that the troubles of the body can be fixed for good. But geriatricians? Who clamors for geriatricians? What geriatricians do—bolster our resilience in old age, our capacity to weather what comes—is both difficult and unappealingly limited. It requires attention to the body and its alterations. It requires vigilance over nutrition, medications, and living situations.

On the plus side, Baltimore has much better weather than St. Paul.

From the article by Boult et al. (you might notice a shift in style from the New Yorker to
the Journal of the American Geriatric Society):

PARTICIPANTS: A population-based sample of community-dwelling Medicare beneficiaries age 70 and older who were at high risk for hospital admission in the future (N = 568).

INTERVENTION: Comprehensive assessment followed by interdisciplinary primary care.

MEASUREMENTS: Functional ability, restricted activity days, bed disability days, depressive symptoms, mortality, Medicare payments, and use of health services. Interviewers were blinded to participants’ group status.

RESULTS: Intention-to-treat analysis showed that the experimental participants were significantly less likely than the controls to lose functional ability (adjusted odds ratio (aOR) = 0.67, 95% confidence interval (CI) = 0.47–0.99), to experience increased health-related restrictions in their daily activities (aOR = 0.60, 95% CI = 0.37–0.96), to have possible depression (aOR = 0.44, 95% CI = 0.20–0.94), or to use home healthcare services (aOR = 0.60, 95% CI = 0.37–0.92) during the 12 to 18 months after randomization. Mortality, use of most health services, and total Medicare payments did not differ significantly between the two groups. The intervention cost $1,350 per person.

CONCLUSION: Targeted outpatient GEM slows functional decline.

P.S. Dennis Miller alert: Since I’m mentioning the New Yorker, I’ll have to link to this again.

4 thoughts on “Effectiveness of geriatric specialists, leading to a brief discussion of the “separate accounts” fallacy in decision making and a comparison of the climates of Baltimore and St. Paul

  1. I can accept that the study is probably valid, it sounds like a plausible conclusion. However, shouldn't it have been done by a non-geriatrician to eliminate observation/expt. design bias? Also, I wonder if the geriatrician would have published the results even if they had found that intervention had no effect at all, or was even harmful (in principle, these are possible outcomes).

    Finally, I have a lot of experience with the medical system in the US; I lived there for about five years, and am a professional patient of sorts because I am a kidney transplant (22 years and counting). The US medical care system is comprehensively broken (as everyone knows); the geriatric care problem is as serious as any other, but the problem lies to a great in the belief that centralized care is somehow a submission to communism. The bottom line is that as long as health insurance companies (rather than doctors) are allowed to dictate who gets care and who does not, nothing will improve across the board. The geriatric care example is just a symptom of a systemic problem, and correcting it will not solve the larger problem.

    This broken system is what led me to leave the US after I finished my PhD. It's a completely irrational system. If you look at Japan's or Germany's (I've lived in both these places, for extended periods), you see an existence proof of what works better than the US system. It's astounding that the US is unable to learn from these countries' experiences (this is not to say that there aren't problems in Japan and Germany, but they are nothing like the scale of problems that the US offers to the chronically ill).

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