I was recently invited to deliver a centennial celebration science address at my high school, which I hadn’t visited in some forty years. In reviewing the content of the lecture, my wife kindly pointed out that the pop culture references I had made were certainly appropriate and witty, but were at least a generation out of date. Age, like beauty, is somewhat in the eye of the beholder. Difficult decisions face us as a nation as we grapple with the healthcare issue. The dual goals of expanding coverage and cutting cost are somewhat paradoxical. Of course the politicians did the expedient thing and opted for the former while deferring the latter (probably until some set of poor souls is in office and facing the bankruptcy of the newly enacted program).
In virtually all studies of morbidity and mortality related to interventions or pathology in cardiovascular medicine and surgery, age is a compelling risk factor. As a somewhat chronic degenerative disease, atherosclerotic coronary artery disease develops over time—sometimes decades, before becoming clinically manifest. The older the patient, likely the greater burden of disease, and the lesser the ability to tolerate the manifestations, consequences and the treatments. Care of the elderly is resource-intense.
And yet, from the point of view of “return on investment,” even favorable results yield at best a limited number of “quality-adjusted life years”—the metric by which medical interventions are judged on a comparative cost basis. Despite the odious nature of the thought, extensive needs in the face of limited resources inevitably requires application of the “R” word—whether we like to admit it or not, rationing occurs by virtue of the choices we make or even by virtue of our failure to make them.
It is for reasons such as these, perhaps with the addition for concerns regarding the limited ability of the elderly to return to the work force that has led many foreign health care systems to restrict certain interventions on the basis of age. Indeed, perhaps even in our own country, where health care availability is not restricted by age, we see screening recommendations for various diseases such as breast cancer terminate at some arbitrary age even though the incidence of the underlying disease does not decline.
Perhaps the best we can hope for is that whatever decisions are made are considered based on the best scientific evidence available at the time. A remarkable study which the Florida Heart Research Institute recently reported to the American Heart Association, demonstrated that the very elderly, those age 80 and older, who underwent coronary artery bypass surgery, with current techniques and care, had a post-operative mortality comparable to their younger counterparts, and a life expectancy comparable to the general age-matched population.
Interestingly enough, when I presented this work, there was a companion paper from another center demonstrating similar findings for heart valve replacement surgery. In fact, some recent studies seem to indicate that careful analysis of risk factors no longer identifies age as an independent predictor of mortality for coronary bypass surgery.
Obviously, there is some pre-selection involved in these retrospective studies—the elderly patients who are accepted for surgery certainly represent a more potentially robust group than the total population of that age with that disease process. However, what is important to realize is that over the course of our study, a twelve year period extending from the late 1980’s to the early 2000’s , the post-operative mortality dropped progressively from around 15% to 2%.
This is a testimony to the advances in surgical and intensive care which is born from experience dealing with these patients. In other words, the underlying commitment to provide these elderly patients with the highest level of care resulted in dramatic improvements; had there not been that commitment, there would likely never have been that improvement. Therefore, before dismissing care of the elderly as too expensive, too resource intensive, or too unrewarding, we as a profession and as a society must pay careful attention to our priorities and our real capabilities.
The Community Living Assistance Services and Support (CLASS) Act will make long-term care insurance, receiving a cash benefit of around $50 a day, available to all Americans.
In South Florida Hospital News and Healthcare Report’s July 2009 issue, we discussed the various definitions and components of the term medical homes. Although we would know a medical home if we experienced it, a generally accepted definition has not yet been determined (see sidebar). With passing of the historic Patient Protection and Affordable Care Act on March 23, 2010, we anticipate that the industry will experience more momentum in the development of medical homes as it copes with the expected increase in demand for services as coverage expands for thirty-two million more Americans and the coming of age of the baby-boomers. The recently passed health reform legislation has given, the secretary of health and human services broad authority to launch new pilot projects based on the patient-centered medical home concept, which is expected to be accomplished under the auspices of the Centers for Medicare and Medicaid Services (CMS).