- Email: [email protected]
America’s Health Care System Is Broken: What Went Wrong and How We Can Fix It. Part 6: Social Factors
ARTICLE IN PRESS REVIEW
America’s Health Care System Is Broken: What Went Wrong and How We Can Fix It. Part 6: Social Factors Edward P Hoffer, MD, FACC, FACP, FACMI a,b a
Associate Professor of Medicine, part-time, Harvard Medical School, Boston, Mass; b Laboratory of Computer Science, Massachusetts General Hospital, Boston.
ABSTRACT Although previous articles in the series have focused on the key players in our health care system, even larger factors that impact the cost and outcome of the nation’s health lie in areas that are not traditionally thought of as “health care.” Diet and exercise play a huge role in longevity and well-being. The best health care systems are unable to do much to lower deaths from firearms and motor vehicle crashes. Changing our focus from health care institutions to how to better support patients in the community will both lower cost and improve satisfaction. We need to learn how to better integrate patients’ wishes into end-of-life care to provide more humanistic as well as less expensive care. © 2019 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2019) xxx:xxx-xxx KEYWORDS: Firearms; Health care system; Lifestyle; Motor vehicle accidents; Poverty; Social supports
A nation’s or an individual’s health status is determined to a large extent by factors other than the health care system. When we see comparisons of such factors as life expectancy, childhood death rates, and maternal death rates between the United States and similar western countries, we are seeing much more than how we pay for and deliver medical care services. The dramatic increase in life expectancy that occurred over the course of the 20th century was a result of improved sanitation, clean water, and safer workplaces rather than better medical care. The lower coronary death rates of the past decade owe more to decreased cigarette smoking than to statins. Let us look at some of these factors in more detail. In 2016, the death rate of children in Europe, including the poorer eastern countries, was less than 20/100,000, but in the United States, it was 26/100,000.1,2 Why is this? In Europe, injuries caused approximately 40% of the deaths, but in the United States, injuries caused 60%. In the United States, Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for the content of this manuscript. Requests for reprints should be addressed to Edward P. Hoffer, MD. Laboratory of Computer Science, Massachusetts General Hospital, 50 Staniford St., Ste. 750, Boston, MA 02114. E-mail address: [email protected]. 0002-9343/© 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amjmed.2019.05.018
motor vehicle crashes and firearm-related injuries together caused 4 times as many deaths in children and adolescents as did cancer.2 Gun violence has become a major public health crisis in this country, to which we seem unable to respond, due largely to the cowardice of our politicians.3 A study looked at death rates among children and teenagers in 16 developed Organization for Economic Cooperation and Development (OECD) countries. US teenagers were 82 times more likely to die at the hands of a gunman than their peers in other countries; among adolescents 15-19, 74% of deaths were the result of motor vehicle crashes, homicides, and suicides.4 Suicide is the 10th-leading cause of death among people age 10 and older and is the 2nd-leading cause of death among youth ages 10-19. Suicides also spike in men older than 65. The means of suicide matter a great deal. Most people who attempt suicide but survive get help, and only a minority repeat the attempt. When the means used is overdosing on pills or cutting their wrist, more than 90% survive a suicide attempt. When a gun is used for suicide, it results in death more than 90% of the time. States with stricter firearm laws, such as Massachusetts, have much lower firearm-related death rates than those with looser regulations. According to the Centers for Disease Control and Prevention (CDC), in 2016 Massachusetts had 3.6 gun deaths per 100,000 people. Neighboring New Hampshire, with looser
ARTICLE IN PRESS 2
The American Journal of Medicine, Vol xxx, No xxx, ▪▪ 2019
regulations, had 9.9/100,000. The 3 states with the highest impact behaviors will require efforts at the larger societal level. rates, Alaska, Alabama and Louisiana, all had more than 21 When low-income populations live in “food deserts” without gun deaths per 100,000 people.5 nearby supermarkets or other sources of healthy food, they Despite some progress, more than 10,000 alcohol-related will gravitate to the convenience stores with their "ultra-procmotor vehicle accident fatalities occur annually in the United essed" high-calorie, high salt, and high fat foods. Local govStates. More stringent state laws ernments should make every on alcohol have been shown to effort to see that healthy foods be associated with lower rates are as easily available and as inof alcohol-related driving fataliCLINICAL SIGNIFICANCE expensive as the alternatives. ties. These laws target drinkingSafer streets and bicycle paths • Our youth are dying because of drugs, guns, and motor oriented policies, such as higher will make it easier for people to vehicle accidents rather than lack of medical care. taxes on alcohol, limits on the walk and bicycle. • Many of the chronic diseases that account for large density of alcohol sales outlets, Broader social policies play a health care expenditures would be better approached and driving-specific policies, major role in our overly expenby lifestyle changes than by medication. such as sobriety checkpoints sive yet underperforming heath • Better social support would allow for more people who and lower limits of blood alcohol care system. Most elders would are elderly and chronically ill to remain at home with at which driving under the influmuch rather be in their own lower costs and greater satisfaction. ence (DUI) is invoked. homes than in hospitals or nurs• Our approach to end-of-life care needs to be changed to I do not need to tell you that ing homes, but our current support quality of life and patient preferences over simwe are in the midst of a major health care system seems to be ply extending life. opioid crisis. Although physiorganized around institutions cians clearly play some role by rather than homes. This is not prescribing narcotics too often only less desirable but much and in overly large quantities, more expensive. even if we stopped prescribing narcotics completely, the probEuropean and other OECD countries spend much less on lem would not disappear. Combatting this epidemic will rehealth care than does the United States but have better health quire cooperation among the medical community, law statistics. This is not necessarily an indictment of US hospitals enforcement, and the courts. and doctors on quality (though it is on cost) because there are When we are not killing each other with motor vehicles and many differences between the United States and our western firearms, we are doing ourselves in by overeating, peer countries besides the way our health care system is orgaoverdrinking, and refusing to exercise. A widely publicized nized. Europeans on average are more physically active than study found that 5 healthy behaviors could add 12-14 years Americans, walking and bicycling more, and less likely to be to the life span of adults who are middle-aged: a healthy overweight or obese. Another important difference is that aldiet, regular exercise, not smoking, maintaining a healthy though European countries spend much less on health care, weight, and moderate alcohol consumption. These factors they spend more on a variety of social services, including famwere associated with reduced rates of cancer, cardiovascular ily and child support and housing. Thus, the United States disease, and overall mortality. The researchers estimated that spends about 18% of its gross domestic product (GDP) on the average life expectancy at age 50 was 14 years longer for health care, and this is 10-12% of GDP in other OECD nawomen with all 5 factors compared to women with none; tions. That said, public spending on social services represents among men, the added life expectancy was 12 years.6 If a 21% of GDP in other countries and 19.3% in the United States. To look at this in another way, for every $1 spent in the US on drug or surgical procedure could come close to these benefits, health care, $0.56 is spent on social services, whereas in other its developer would be bound for Stockholm! A study looking OECD countries, for every $1 spent on health care, $1.70 is at the health effects of diet around the world estimated that spent on social services. How does this difference in spending 20% of all deaths were related to such dietary risk factors as priorities affect our health outcomes? As noted in Prescription excess sodium and inadequate intake of fruit and fiber.7 Diet for Bankruptcy, maternal death rates in the United States are was found to have a dramatic effect on the development of dramatically worse than in other OECD nations, and infant heart failure in US adults without coronary disease. A plantdeath rates are worse even though we have many more neonabased diet led to 41% less congestive heart failure (CHF), tal intensive care beds. Much of this can be attributed to the whereas a “Southern” diet was associated with 71% higher indifferent ways new mothers are treated. In most OECD councidence of heart failure.8 Better-quality dietary patterns in tries, generous paid maternity leave is the norm, whereas in the adulthood were associated with better cognitive performance United States, if it is offered at all, it is likely to be unpaid. This in midlife.9 Exercise, even in modest amounts, is associated is clearly a reason why half of new mothers in the United with less all-cause, cancer, and cardiovascular mortality and States do not even keep their 6-week postpartum checks. with less dementia.10,11 Despite this, we as physicians are Two studies published last fall showed how provision of not doing a good job of encouraging lifestyle changes, perhaps better social services can impact both quality and cost of health because of the low observed success rate.12 Nor do workplace care. One, published in JAMA Internal Medicine in October, “wellness” programs appear to have a meaningful effect.13 To
ARTICLE IN PRESS Hoffer
Hoffer America’s Health Care System Is Broken: Social Factors
looked at the impact of community health workers on the health outcomes of a group of low-income veterans cared for at a Veterans Administration (VA) hospital in Philadelphia. These elderly veterans had at least 2 chronic diseases and lived in high-poverty census tracts. Not only did the veterans who were visited by community health workers report greater satisfaction with their health and with their care, but they also experienced 65% fewer hospital days over the 9 months of the study compared with a similar group who did not have these visits.14 A study published the same month in Health Affairs looked at how supportive social services supplied to elderly residents of Queens impacted their hospital use. The group studied were residents of subsidized elder housing units who were matched in every way except that 1 group had access to a variety of inhome services. These included counseling, home safety assessments, wellness and socialization programs, assistance with accessing government programs and in transportation. The group that got these services, compared to a similar group living nearby without them, had 32% fewer hospitalizations, and when they were hospitalized, they went home sooner.15 Increasing social support clearly works. How to finance it is problematic. For large agencies that are globally budgeted, such as the VA or the new Medicare Accountable Care Organizations, a good case can be made for them to plunge in and spend the money and expect a good return on their investment. For the nation as a whole, policy makers must be made to understand that investing in these low-tech services may give a bigger bang for the buck than many other ways the money can be spent. Spending money on improved social support will not only make our most vulnerable citizens happier, but in the long run, it will also save money. End-of-life care represents a major challenge because it is often of little benefit to the patients, affects many people, and is expensive. Many patients dying in the United States receive medical care that gives little or no improvement in their outcome and is all too often at odds with their wishes. Even though 80% of patients say that hospitalization or stays in the intensive care unit at the end of life impose unwanted burdens, about one-third of deaths in this country occur in the hospital. It has been estimated that 25% of Medicare payments go to patients in their last year of life. The key question is not cost but value: are we spending hundreds of billions of dollars on care that does not help patients but may instead harm them? When asked, most elders would prefer to die at home, in comfort. and surrounded by their loved ones and not surrounded by strangers in the alien environment of the intensive care unit with tubes in every part of their body and daily, multiple blood draws in their worn-out veins. Why the discordance between what patients say they want done and the care provided? Part of the blame lies with us. Doctors are often reluctant to be open and honest with patients with a poor prognosis. It is much easier to say, “Let’s try this,” than to admit that no available treatment will make a major difference. It has been shown that physicians’ beliefs and training influence care much more than patients’ beliefs—exactly the
3
opposite of what should happen. Part of the blame lies with families who are reluctant to accept inevitable death and insist that doctors “do everything,” even when they are told it will not help. It is easy and natural to reject what the doctors are saying. “Most people like this will die soon, but not my Dad.” All too often I have been in the situation in which a patient told me they are ready to accept a comfortable death, but then a child flies in from far away and insists that I “do everything.” Even when there are several children who agree to let a parent die peacefully, doctors tend to heed the children who insist on aggressive care because they are the ones who threaten to sue if their parent is not given “everything.” Focusing on treating a patient’s symptoms near the end of life rather than on extending life often carries an unexpected bonus: a longer and a better life. There is now evidence that patients with cancer and end-stage heart failure live longer when enrolled in hospice and other palliative care programs.16, 17 The patients with advanced heart failure who were enrolled in hospice had fewer visits to the emergency department, fewer hospital days, were less likely to die in the hospital, and lived slightly longer than those getting traditional “active” care.17 There is much that can and must be done through better public policy initiatives to improve our national health outcomes, and although doctors and hospitals can do a lot of things differently, we cannot do it all. While not usually thought of in the context of improving health, helping lift the working poor out of poverty through a higher minimum wage would do wonders. As eloquently stated by Matthew Desmond, “A living wage is an antidepressant. It is a sleep aid. A diet. A stress reliever. It is a contraceptive, preventing teenage pregnancy. It prevents premature death. It shields children from neglect.”18 Good health is not just the result of the actions of health care personnel, but as leaders in health care, doctors and nurses must advocate for the larger issues for the sake of our patients.
References 1. Kyu HH, Pinto CB, Rakovac I, et al. Causes of death among children 514 years in the WHO European Region: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Child Adolesc Health 2018;2:321-37. 2. Cunningham RM, Walton MA, Carter PM. the major causes of death in children and adolescents in the United States. New Engl J Med 2018;379(25):2468-75. 3. Bauchner H, Rivara FP, Bono RO, et al. Death by gun violence – a public health crisis. JAMA Intern Med 2017;177(12):1724-5. 4. Thakar AP, Forrest AD, Maltenfort MG, Forrest CB. Child mortality in the US and 19 OECD Comparator nations: a 5-year time-trend analysis. Health Aff 2018;37(1):140-9. 5. Kegler SR, Dahlberg LL, Mercy JA. Firearm homicides and suicides in major metropolitan areas - United States, 2012-2013 and 2015-2016. MMWR Morb Mortal Wkly Rep 2018 Nov 9;67(44):1233-7. 6. Li Y, Pan A, Wang DD, et al. Impact of healthy lifestyle factors on life expectancies in the US population. Circulation 2018;138:345-55. 7. GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 [epub ahead of print]. Lancet. 2019 Apr 3. pii: S0140-6736 (19)30041-8. doi: 10.1016/S0140-6736(19)30041-8.
ARTICLE IN PRESS 4 8. Lara KM, Levitan EB, Gutierrez OM, et al. Dietary patterns and incident heart failure in U.S. adults without known coronary disease. J Am Coll Cardiol 2019;73:2036-45. 9. McEvoy CT, Hoang T, Sidney S, et al. Dietary patterns during adulthood and cognitive performance in midlife. Neurology 2019 Apr 2;92(14): e1589-99. 10. Zhao M, Veeranki SP, Li S, et al. Beneficial associations of low and large doses of leisure time physical activity with all-cause, cardiovascular disease and cancer mortality: a national cohort study of 88,140 US adults [epub ahead of print]. , Brit J Sports Med. 2019 Mar 19. pii: bjsports2018-099254. doi: 10.1136/bjsports-2018-099254. 11. Najar J, Ostling S, Gudmundsson P, et al. Cognitive and physical activity and dementia. Neurology 2019;92:e1322-30. 12. Grabovac I, Smith L, Stefanac S, et al. Health care providers’ advice on lifestyle modification in the US population: results from the NHNES 2011-2016. Am J Med 2019;132:489-97. 13. Song Z, Baicker K. Effect of a workplace wellness program on employee health and economic outcomes. JAMA 2019;321(15):1491-501.
The American Journal of Medicine, Vol xxx, No xxx, ▪▪ 2019
14. Kangovi S, Mitra N, Norton L. Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities. JAMA Intern Med 2018;178(12):1635-43. 15. Gusmano MK, Rodwin VG, Weisz D. Medicare beneficiaries living in housing with supportive services experienced lower hospital use than others. Health Aff 2018;37(10):1562-9. 16. Greer JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic nonsmall-cell lung cancer. J Clin Oncol 2011;30:394-400. 17. Gelfman LP, Barron Y, Moore S, et al. Predictors of hospice enrollment for patients with advanced heart failure and effects on health care use. JACC Heart Failure 2018;6:780-9. 18. Desmond M. Dollars on the Margins: , https://www.nytimes.com/ interactive/2019/02/21/magazine/minimum-wage-saving-lives.html. Accessed May 14, 2019.
America’s Health Care System Is Broken: What Went Wrong and How We Can Fix It. Part 6: Social Factors Edward P Hoffer, MD, FACC, FACP, FACMI a,b a
Associate Professor of Medicine, part-time, Harvard Medical School, Boston, Mass; b Laboratory of Computer Science, Massachusetts General Hospital, Boston.
ABSTRACT Although previous articles in the series have focused on the key players in our health care system, even larger factors that impact the cost and outcome of the nation’s health lie in areas that are not traditionally thought of as “health care.” Diet and exercise play a huge role in longevity and well-being. The best health care systems are unable to do much to lower deaths from firearms and motor vehicle crashes. Changing our focus from health care institutions to how to better support patients in the community will both lower cost and improve satisfaction. We need to learn how to better integrate patients’ wishes into end-of-life care to provide more humanistic as well as less expensive care. © 2019 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2019) xxx:xxx-xxx KEYWORDS: Firearms; Health care system; Lifestyle; Motor vehicle accidents; Poverty; Social supports
A nation’s or an individual’s health status is determined to a large extent by factors other than the health care system. When we see comparisons of such factors as life expectancy, childhood death rates, and maternal death rates between the United States and similar western countries, we are seeing much more than how we pay for and deliver medical care services. The dramatic increase in life expectancy that occurred over the course of the 20th century was a result of improved sanitation, clean water, and safer workplaces rather than better medical care. The lower coronary death rates of the past decade owe more to decreased cigarette smoking than to statins. Let us look at some of these factors in more detail. In 2016, the death rate of children in Europe, including the poorer eastern countries, was less than 20/100,000, but in the United States, it was 26/100,000.1,2 Why is this? In Europe, injuries caused approximately 40% of the deaths, but in the United States, injuries caused 60%. In the United States, Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for the content of this manuscript. Requests for reprints should be addressed to Edward P. Hoffer, MD. Laboratory of Computer Science, Massachusetts General Hospital, 50 Staniford St., Ste. 750, Boston, MA 02114. E-mail address: [email protected]. 0002-9343/© 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amjmed.2019.05.018
motor vehicle crashes and firearm-related injuries together caused 4 times as many deaths in children and adolescents as did cancer.2 Gun violence has become a major public health crisis in this country, to which we seem unable to respond, due largely to the cowardice of our politicians.3 A study looked at death rates among children and teenagers in 16 developed Organization for Economic Cooperation and Development (OECD) countries. US teenagers were 82 times more likely to die at the hands of a gunman than their peers in other countries; among adolescents 15-19, 74% of deaths were the result of motor vehicle crashes, homicides, and suicides.4 Suicide is the 10th-leading cause of death among people age 10 and older and is the 2nd-leading cause of death among youth ages 10-19. Suicides also spike in men older than 65. The means of suicide matter a great deal. Most people who attempt suicide but survive get help, and only a minority repeat the attempt. When the means used is overdosing on pills or cutting their wrist, more than 90% survive a suicide attempt. When a gun is used for suicide, it results in death more than 90% of the time. States with stricter firearm laws, such as Massachusetts, have much lower firearm-related death rates than those with looser regulations. According to the Centers for Disease Control and Prevention (CDC), in 2016 Massachusetts had 3.6 gun deaths per 100,000 people. Neighboring New Hampshire, with looser
ARTICLE IN PRESS 2
The American Journal of Medicine, Vol xxx, No xxx, ▪▪ 2019
regulations, had 9.9/100,000. The 3 states with the highest impact behaviors will require efforts at the larger societal level. rates, Alaska, Alabama and Louisiana, all had more than 21 When low-income populations live in “food deserts” without gun deaths per 100,000 people.5 nearby supermarkets or other sources of healthy food, they Despite some progress, more than 10,000 alcohol-related will gravitate to the convenience stores with their "ultra-procmotor vehicle accident fatalities occur annually in the United essed" high-calorie, high salt, and high fat foods. Local govStates. More stringent state laws ernments should make every on alcohol have been shown to effort to see that healthy foods be associated with lower rates are as easily available and as inof alcohol-related driving fataliCLINICAL SIGNIFICANCE expensive as the alternatives. ties. These laws target drinkingSafer streets and bicycle paths • Our youth are dying because of drugs, guns, and motor oriented policies, such as higher will make it easier for people to vehicle accidents rather than lack of medical care. taxes on alcohol, limits on the walk and bicycle. • Many of the chronic diseases that account for large density of alcohol sales outlets, Broader social policies play a health care expenditures would be better approached and driving-specific policies, major role in our overly expenby lifestyle changes than by medication. such as sobriety checkpoints sive yet underperforming heath • Better social support would allow for more people who and lower limits of blood alcohol care system. Most elders would are elderly and chronically ill to remain at home with at which driving under the influmuch rather be in their own lower costs and greater satisfaction. ence (DUI) is invoked. homes than in hospitals or nurs• Our approach to end-of-life care needs to be changed to I do not need to tell you that ing homes, but our current support quality of life and patient preferences over simwe are in the midst of a major health care system seems to be ply extending life. opioid crisis. Although physiorganized around institutions cians clearly play some role by rather than homes. This is not prescribing narcotics too often only less desirable but much and in overly large quantities, more expensive. even if we stopped prescribing narcotics completely, the probEuropean and other OECD countries spend much less on lem would not disappear. Combatting this epidemic will rehealth care than does the United States but have better health quire cooperation among the medical community, law statistics. This is not necessarily an indictment of US hospitals enforcement, and the courts. and doctors on quality (though it is on cost) because there are When we are not killing each other with motor vehicles and many differences between the United States and our western firearms, we are doing ourselves in by overeating, peer countries besides the way our health care system is orgaoverdrinking, and refusing to exercise. A widely publicized nized. Europeans on average are more physically active than study found that 5 healthy behaviors could add 12-14 years Americans, walking and bicycling more, and less likely to be to the life span of adults who are middle-aged: a healthy overweight or obese. Another important difference is that aldiet, regular exercise, not smoking, maintaining a healthy though European countries spend much less on health care, weight, and moderate alcohol consumption. These factors they spend more on a variety of social services, including famwere associated with reduced rates of cancer, cardiovascular ily and child support and housing. Thus, the United States disease, and overall mortality. The researchers estimated that spends about 18% of its gross domestic product (GDP) on the average life expectancy at age 50 was 14 years longer for health care, and this is 10-12% of GDP in other OECD nawomen with all 5 factors compared to women with none; tions. That said, public spending on social services represents among men, the added life expectancy was 12 years.6 If a 21% of GDP in other countries and 19.3% in the United States. To look at this in another way, for every $1 spent in the US on drug or surgical procedure could come close to these benefits, health care, $0.56 is spent on social services, whereas in other its developer would be bound for Stockholm! A study looking OECD countries, for every $1 spent on health care, $1.70 is at the health effects of diet around the world estimated that spent on social services. How does this difference in spending 20% of all deaths were related to such dietary risk factors as priorities affect our health outcomes? As noted in Prescription excess sodium and inadequate intake of fruit and fiber.7 Diet for Bankruptcy, maternal death rates in the United States are was found to have a dramatic effect on the development of dramatically worse than in other OECD nations, and infant heart failure in US adults without coronary disease. A plantdeath rates are worse even though we have many more neonabased diet led to 41% less congestive heart failure (CHF), tal intensive care beds. Much of this can be attributed to the whereas a “Southern” diet was associated with 71% higher indifferent ways new mothers are treated. In most OECD councidence of heart failure.8 Better-quality dietary patterns in tries, generous paid maternity leave is the norm, whereas in the adulthood were associated with better cognitive performance United States, if it is offered at all, it is likely to be unpaid. This in midlife.9 Exercise, even in modest amounts, is associated is clearly a reason why half of new mothers in the United with less all-cause, cancer, and cardiovascular mortality and States do not even keep their 6-week postpartum checks. with less dementia.10,11 Despite this, we as physicians are Two studies published last fall showed how provision of not doing a good job of encouraging lifestyle changes, perhaps better social services can impact both quality and cost of health because of the low observed success rate.12 Nor do workplace care. One, published in JAMA Internal Medicine in October, “wellness” programs appear to have a meaningful effect.13 To
ARTICLE IN PRESS Hoffer
Hoffer America’s Health Care System Is Broken: Social Factors
looked at the impact of community health workers on the health outcomes of a group of low-income veterans cared for at a Veterans Administration (VA) hospital in Philadelphia. These elderly veterans had at least 2 chronic diseases and lived in high-poverty census tracts. Not only did the veterans who were visited by community health workers report greater satisfaction with their health and with their care, but they also experienced 65% fewer hospital days over the 9 months of the study compared with a similar group who did not have these visits.14 A study published the same month in Health Affairs looked at how supportive social services supplied to elderly residents of Queens impacted their hospital use. The group studied were residents of subsidized elder housing units who were matched in every way except that 1 group had access to a variety of inhome services. These included counseling, home safety assessments, wellness and socialization programs, assistance with accessing government programs and in transportation. The group that got these services, compared to a similar group living nearby without them, had 32% fewer hospitalizations, and when they were hospitalized, they went home sooner.15 Increasing social support clearly works. How to finance it is problematic. For large agencies that are globally budgeted, such as the VA or the new Medicare Accountable Care Organizations, a good case can be made for them to plunge in and spend the money and expect a good return on their investment. For the nation as a whole, policy makers must be made to understand that investing in these low-tech services may give a bigger bang for the buck than many other ways the money can be spent. Spending money on improved social support will not only make our most vulnerable citizens happier, but in the long run, it will also save money. End-of-life care represents a major challenge because it is often of little benefit to the patients, affects many people, and is expensive. Many patients dying in the United States receive medical care that gives little or no improvement in their outcome and is all too often at odds with their wishes. Even though 80% of patients say that hospitalization or stays in the intensive care unit at the end of life impose unwanted burdens, about one-third of deaths in this country occur in the hospital. It has been estimated that 25% of Medicare payments go to patients in their last year of life. The key question is not cost but value: are we spending hundreds of billions of dollars on care that does not help patients but may instead harm them? When asked, most elders would prefer to die at home, in comfort. and surrounded by their loved ones and not surrounded by strangers in the alien environment of the intensive care unit with tubes in every part of their body and daily, multiple blood draws in their worn-out veins. Why the discordance between what patients say they want done and the care provided? Part of the blame lies with us. Doctors are often reluctant to be open and honest with patients with a poor prognosis. It is much easier to say, “Let’s try this,” than to admit that no available treatment will make a major difference. It has been shown that physicians’ beliefs and training influence care much more than patients’ beliefs—exactly the
3
opposite of what should happen. Part of the blame lies with families who are reluctant to accept inevitable death and insist that doctors “do everything,” even when they are told it will not help. It is easy and natural to reject what the doctors are saying. “Most people like this will die soon, but not my Dad.” All too often I have been in the situation in which a patient told me they are ready to accept a comfortable death, but then a child flies in from far away and insists that I “do everything.” Even when there are several children who agree to let a parent die peacefully, doctors tend to heed the children who insist on aggressive care because they are the ones who threaten to sue if their parent is not given “everything.” Focusing on treating a patient’s symptoms near the end of life rather than on extending life often carries an unexpected bonus: a longer and a better life. There is now evidence that patients with cancer and end-stage heart failure live longer when enrolled in hospice and other palliative care programs.16, 17 The patients with advanced heart failure who were enrolled in hospice had fewer visits to the emergency department, fewer hospital days, were less likely to die in the hospital, and lived slightly longer than those getting traditional “active” care.17 There is much that can and must be done through better public policy initiatives to improve our national health outcomes, and although doctors and hospitals can do a lot of things differently, we cannot do it all. While not usually thought of in the context of improving health, helping lift the working poor out of poverty through a higher minimum wage would do wonders. As eloquently stated by Matthew Desmond, “A living wage is an antidepressant. It is a sleep aid. A diet. A stress reliever. It is a contraceptive, preventing teenage pregnancy. It prevents premature death. It shields children from neglect.”18 Good health is not just the result of the actions of health care personnel, but as leaders in health care, doctors and nurses must advocate for the larger issues for the sake of our patients.
References 1. Kyu HH, Pinto CB, Rakovac I, et al. Causes of death among children 514 years in the WHO European Region: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Child Adolesc Health 2018;2:321-37. 2. Cunningham RM, Walton MA, Carter PM. the major causes of death in children and adolescents in the United States. New Engl J Med 2018;379(25):2468-75. 3. Bauchner H, Rivara FP, Bono RO, et al. Death by gun violence – a public health crisis. JAMA Intern Med 2017;177(12):1724-5. 4. Thakar AP, Forrest AD, Maltenfort MG, Forrest CB. Child mortality in the US and 19 OECD Comparator nations: a 5-year time-trend analysis. Health Aff 2018;37(1):140-9. 5. Kegler SR, Dahlberg LL, Mercy JA. Firearm homicides and suicides in major metropolitan areas - United States, 2012-2013 and 2015-2016. MMWR Morb Mortal Wkly Rep 2018 Nov 9;67(44):1233-7. 6. Li Y, Pan A, Wang DD, et al. Impact of healthy lifestyle factors on life expectancies in the US population. Circulation 2018;138:345-55. 7. GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017 [epub ahead of print]. Lancet. 2019 Apr 3. pii: S0140-6736 (19)30041-8. doi: 10.1016/S0140-6736(19)30041-8.
ARTICLE IN PRESS 4 8. Lara KM, Levitan EB, Gutierrez OM, et al. Dietary patterns and incident heart failure in U.S. adults without known coronary disease. J Am Coll Cardiol 2019;73:2036-45. 9. McEvoy CT, Hoang T, Sidney S, et al. Dietary patterns during adulthood and cognitive performance in midlife. Neurology 2019 Apr 2;92(14): e1589-99. 10. Zhao M, Veeranki SP, Li S, et al. Beneficial associations of low and large doses of leisure time physical activity with all-cause, cardiovascular disease and cancer mortality: a national cohort study of 88,140 US adults [epub ahead of print]. , Brit J Sports Med. 2019 Mar 19. pii: bjsports2018-099254. doi: 10.1136/bjsports-2018-099254. 11. Najar J, Ostling S, Gudmundsson P, et al. Cognitive and physical activity and dementia. Neurology 2019;92:e1322-30. 12. Grabovac I, Smith L, Stefanac S, et al. Health care providers’ advice on lifestyle modification in the US population: results from the NHNES 2011-2016. Am J Med 2019;132:489-97. 13. Song Z, Baicker K. Effect of a workplace wellness program on employee health and economic outcomes. JAMA 2019;321(15):1491-501.
The American Journal of Medicine, Vol xxx, No xxx, ▪▪ 2019
14. Kangovi S, Mitra N, Norton L. Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities. JAMA Intern Med 2018;178(12):1635-43. 15. Gusmano MK, Rodwin VG, Weisz D. Medicare beneficiaries living in housing with supportive services experienced lower hospital use than others. Health Aff 2018;37(10):1562-9. 16. Greer JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic nonsmall-cell lung cancer. J Clin Oncol 2011;30:394-400. 17. Gelfman LP, Barron Y, Moore S, et al. Predictors of hospice enrollment for patients with advanced heart failure and effects on health care use. JACC Heart Failure 2018;6:780-9. 18. Desmond M. Dollars on the Margins: , https://www.nytimes.com/ interactive/2019/02/21/magazine/minimum-wage-saving-lives.html. Accessed May 14, 2019.