Our interview with Lucy Kalanithi, an innovative care pilot, and drug use among the eldery

August 4, 2016

In order to bring you more of the news you want to read, RightCare Weekly summarizes and interprets three important articles and provides headlines linking to the many other articles and editorials you’ll find interesting. As always, RightCare Weekly presents articles related to moving our healthcare system toward the right care for all patients.

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Paul Kalanithi’s inspiring memoir, When Breath Becomes Air, is a portrait of the neurosurgeon who faces stage IV lung cancer and is determined to live with purpose up until the end. The book, published earlier this year to rave reviews, features a moving epilogue written by his widow, Lucy, whom we interviewed for the Lown Institute blog. She recalls the power of language when Paul was dying, the difficult choices he made, and his insistence on finishing the book despite frequent fatigue. While decisions to treat or not at the end of life are difficult for patients, Lucy believes that, deep down, many patients might be eager to have the conversation. Who should bring up the topic first, doctors or patients, she questions. “Avoidance of talking about death leads us away from living well until we die,” she said. In the book’s epilogue, Lucy writes, “Even while terminally ill, Paul was fully alive; despite physical collapse, he remained vigorous, open, full of hope not for an unlikely cure, but for days that were full of purpose and meaning.” Paul also leaves behind a daughter, Cady, born eight months before he died; the book is dedicated to her. (“You filled a dying man’s days with sated joy. A joy unknown to me in all my prior years.”)

Maryland hospitals and the Centers for Medicare & Medicaid began an innovative experiment two and a half years ago, trying to determine if a community-based approach to care could reduce costs while keeping people healthy and out of hospital settings. Already the five-year pilot is showing promise, with dropping readmission rates, fewer hospital-acquired conditions and reductions in avoidable hospital visits. Payments are based on residents receiving “the right care, at the right time, in the right setting,” according to an article in Fierce Healthcare, and not on the number of patients treated or procedures performed. The Maryland Faith Network was instrumental in the effort, connecting hospitals with houses of faith to help congregants navigate the healthcare system. Also noteworthy were other programs that the hospitals conceived, such as a care van offering free screenings and “prescriptions” for healthy foods, which are discounts for healthy foods. Carmela Coyle, CEO of the Maryland Hospital Association, who authored the piece, highlights the importance of engaging the public in healthcare. “Care delivery transformation cannot be solely about offering different programs to patients; communities must take advantage of them as well, and they will need to be proactive in making lifestyle changes that can help them avoid unnecessary hospital visits.”

Nearly 60 percent of Americans take at least one prescription drug, many of them elderly, according to a recent JAMA article. This week, Ravi Parikh, MD, in The Washington Post, explains why it’s so hard for doctors to “de-prescribe” medicines for elderly patients, citing “the truth that physicians fail to acknowledge: When patients expect treatment, we are more likely to prescribe a drug—whether medication is needed or not.” Parikh worries that as patients’ medication lists grow, so do the many side effects. Often patients want to stay on a drug that has helped them, even if it was prescribed for a condition that was temporary, he said. Parikh confesses that discontinuing a drug, if prescribed by another physician, gives doctors pause, because “we physicians hesitate to step on another doctor’s toes.” Adding to the mix of drug overuse is the ease with which electronic health records renew a script in lieu of having lengthier doctor-patient discussions about drug use, which are difficult to do during 15-minute office visits. Parikh suggests that evidence-based prognosis calculators might guide doctors in deciding whether there are long term benefits of certain drugs prescribed for seniors. He also recommends a public awareness campaign that focuses on direct-to-consumer drug de-prescribing. “Just as awareness campaigns suggest talking to your doctor about heart disease and smoking, a similar campaign could be geared toward asking your doctor to de-prescribe,” he said.




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