Paul Tatum

Primary prevention of diseases of old age

The approach to preventing disabling conditions assumes a different shape as people age. In middle age, relatively few are disabled; however, with increasing age, disability becomes more common and remaining life expectancy shortens. Nonetheless, average life expectancy for a 65-year-old individual is still 17.7 years [1]. A person who reaches 65 years of age in good health may have a quarter or more of his or her life remaining. Interventions designed to prevent disability are particularly appropriate in such individuals. On the other hand, among severely cognitively impaired 88 year olds, most families and physicians would only consider interventions aimed at preserving or improving quality of life; although a few might still place considerable weight on simply extending life. This article discusses the general and special criteria needed to evaluate preventive services in the elderly. It then assesses specific screening, counseling, and treatment interventions to prevent disabling conditions in old age. It also briefly considers approaches to providing effective office-based preventive care and how current biomedical research may alter our approach to prevention in the future.

The Role of the Hospice Medical Director as Observed in Interdisciplinary Team Case Reviews

BACKGROUND The purpose of this study was to observe the roles played by six hospice medical directors from two hospice programs during interdisciplinary team case reviews. METHODS The study analyzed videotapes of case reviews in two hospice agencies over a two year period. The results indicate that the roles and levels of participation vary. Medical Directors were observed reviewing and assisting with care plans, acting as a liaison with primary physicians, educating staff, consulting with attending physicians, participating in quality assurance activities, and dealing with budget issues. RESULTS Medical Directors did not make home visits or assume the role of attending physician during the observation period. CONCLUSIONS The study demonstrates variance in roles among medical directors and raises new questions for future research.

Interdisciplinary collaboration: the voices of hospice medical directors.

The value of interdisciplinary collaboration is a significant aspect of the palliative care philosophy, as identified by the founder of the modern hospice movement Cecily Saunders. The purpose of this descriptive study was to explore the experiences of hospice medical directors within this collaborative context. Open-ended interviews with 17 hospice medical directors were done and their responses were thematically analyzed. These narratives present a very positive collaborative experience by these medical directors in their hospice settings. Assisting medical directors to find time and financial opportunities for professional development and support within their role was found to be an opportunity to further improve collaboration.

Hospice medical directors: a survey of one state.

INTRODUCTION Little research exists regarding hospice medical directors (HMD). This project describes the HMDs background and training, clinical roles, and current function within the hospice organization and their interdisciplinary groups. METHODS A survey was mailed to each licensed hospice that was also a member of the state hospice association in one state. Thirty-one HMDs from 31 hospice programs (40% response rate) in one state responded. RESULTS Findings show that the role of the HMD in this state is primarily part-time and filled by primary care physicians. Most HMDs report being satisfied with their positions. No more than one third belong to any one professional association and no physician in this survey was certified in palliative care by the American Board of Medical Specialties. The role for most of these HMDs centers around their clinical contribution to the team. DISCUSSION Despite the 2008 revisions in the regulations, the HMD roles still vary across hospices, and requirements regarding the specialty, training, and education for physicians are not specified. Professional associations for HMDs should target these part-time physicians in an effort to build a comprehensive organization represented by all types of HMDs. CONCLUSION The part-time nature of HMDs has important implications for professional organizations and policy makers. Palliative care certification and continuing education opportunities need to be made available to these physicians. Additionally, new changes requiring face-to-face visits for recertification should consider the part-time nature of HMD work and the difficulties that the requirement will have in both cost for the hospice and access to primary care in rural areas.

The Medical Director as a Member of the Hospice Team

In this issue of the Journal of the American Medical Directors Association, Vandenberg and Keller provide a literature review illustrating the lack of research related to hospice medical directors and outlining important considerations for those interested in providing medical leadership in a hospice. They cite only 7 articles related to hospice medical direction, and discover only 1 provides data related to the practice. Their article demonstrates that further research into what makes the medical director effective within the structure of the hospice interdisciplinary team is paramount. The early development of palliative medicine as a distinct discipline parallels the development of the American Medical Directors Association (AMDA). Most of the pioneers advocating for specialty status have been physicians who were either actively serving as hospice medical directors or had previously done so. In the early days following the implementation of the Medicare hospice benefit in 1984, hospice administrators, strapped for resources, called on physician friends, requesting assistance with the hospice, and when starting a program, asking if they would volunteer assistance in serving this special population. As hospices grew, the need for different arrangements arose, medical directors became paid, and ultimately hospices even hired more than one physician. The Medicare Conditions of Participation (COPs), although recently revised, have not changed the role and qualifications of hospice medical directors. Those regulations state only 1 requirement: they need to be a licensed medical or osteopathic physician. A license to practice medicine is all that is required. There is no mention of certification, continuing education, or palliative care or hospice experience. Although the American Board of Medical Specialties has designated the practice of hospice and palliative medicine as a subspecialty, the hospice regulations do not recognize it. There are no specialty or subspecialty requirements in the regulations; indeed, there is no residency requirement. Technically, a licensed physician of any kind may become a hospice medical director. Ironically, the same is true for nursing and social work; educational credentials are suffi-

Hip Fractures in Patients With Advanced Dementia: What Treatment Provides the Best Palliation?

Nursing home residents sustaining a hip fracture have poor outcomes both in terms of survival and ambulation. Using US Medicare data on nursing home residents from 2005 through 2009, Neuman and colleagues1 found that by 6 months after the fracture, 36.2% had died; moreover, among residents who were not totally dependent in prefracture locomotion, 54% had either died or developed new total dependence. Nonetheless, unless patients are imminently dying, conventional wisdom suggests that the advantages of repairing hip fractures in terms of managing pain and facilitating mobility usually outweigh the disadvantages. These issues are particularly pertinent for nursing home residents with advanced dementia for whom a goal of maintaining comfort is often the predominant preference of their proxy decision maker.2 However, the literature contains limited information to guide proxy decision makers regarding shortand long-term outcomes of operative or nonoperative management of hip fracture in these patients. In this issue of JAMA Internal Medicine, Berry and colleagues3 use Medicare claims and nursing home Minimum Data Set (MDS) data to report on several outcomes of nursing home residents with advanced dementia whose hip fractures were treated operatively (85%) or nonoperatively (15%).3 By 6 months after fracture, deaths occurred in 31.5% of those treated surgically and 53.8% of those treated without surgery. One might have expected an even higher figure for the nonoperative group. Although we are not presented exact figures for earlier mortality, including in-hospital mortality, the survival curve in the nonoperative cohort drops much more steeply in the first few months following the fracture. Consistent with this, the adjusted median survival is only 0.4 years in the nonoperative group. Among survivors, MDS assessments between 120 and 240 days following the fracture showed that 29% and 31% of residents reported pain among those treated operatively and nonoperatively, respectively. Antipsychotic use was more common in the operative group (29.5% vs 20.4%), and pressure sores were more common in the nonoperative group (19% vs 11%); however, neither of these results was statistically significant. There are many methodological strengths in this study3; however, as with all observational studies of treatment, there are issues in interpreting the results. Residents treated nonoperatively were much more impaired at baseline than those in the operative group, which likely influenced both the choice not to operate and their poor outcomes. For example, 26% of residents in the nonoperative group were completely dependent in their activities of daily living, as opposed to 5% in the surgical group. Similarly, only 10.5% of those in the nonoperative group were fully ambulatory prior to the fracture compared with 31.8% in the operative group. The authors used a multivariable Related article page 774 Research Original Investigation Surgical Repair of Hip Fracture in Nursing Home Residents With Advanced Dementia

Where’s the Family? Successfully Bringing the Family into Hospice IDG (FR430)

Discuss the benefits and challenges of involving family in IDG meetings. Problem solve potential changes to the IDG meeting that might better facilitate shared decision-making with family members. Hospice principles define patients and family members as one unit of care. Although empowered to make decisions regarding care, patients and family members are routinely absent from the interdisciplinary group meetings where key decisions are made. Given the lack of direct patient and family input, care plans can suffer from incorrect assumptions about the patient and family perspectives and experiences. We have been testing the use of webconferencing to bring family members into the hospice interdisciplinary group meeting to share in decision-making related to care. Caregivers have reported that this virtual team meeting is beneficial and that they feel as though they are sitting at the table with the team. They feel better informed and a part of the care process. Our research has found that there are clinical benefits to caregivers who are involved and informed as a result of participating in this decision-

Be the Change. An Advocacy Boot Camp (P18) Sponsored by the AAHPM Public Policy Committee

Be the Change. An Advocacy Boot Camp (P18) Sponsored by the AAHPM Public Policy Committee Sue Ramthun Hart Health Strategies, Washington, DC. Phillip E. Rodgers, MD FAAHPM, University of Michigan, Ann Arbor, MI. Paul E. Tatum III, MD MSPH CMD AGSF FAAHPM, University of Missouri, Columbia, MO. Ruth M. Thomson, DO HMDC FACOI FAAHPM, Hospice of Dayton, Inc., Dayton, OH. Gregg K. VandeKieft, MD MA FAAHPM, Providence St. Peter Hospital, Olympia, WA.