Chronic Elderly Patients: new evaluative proposals for community programs

Marco Inzitari

In recent years, we have witnessed the implementation of various community programs based on proactive monitoring and secondary prevention interventions aiming to improve the health of chronically ill patients and reduce costs to the system, such as avoiding unnecessary hospitalizations. But when studies have been conducted to evaluate the effectiveness and efficiency of these studies, the results have been rather poor.

Some of these disappointing results were presented during the Congress of the European Union Geriatric Medicine Society (EUGMS). The symposium called "Strategies in primary care to promote the autonomy of frail elderly people" presented the preliminary results of three large randomized cluster studies (cluster Randomized Clinical Trial) of the Netherlands:

Contradictions of today’s medicine according to Dr. McCartney

Dr. Margaret McCartney, a Scottish family doctor and regular contributor to the BMJ, is the author of "The Patient Paradox" a book with a critical scientific view written in the office. I regularly follow Dr. McCartney’s contributions and two of her tweets have already been selected as tweet of the week in this blog. "Cancer: Are military metaphors appropriate?" and "If we don’t die of cancer, what do we die of?". On June 17 I had the opportunity to listen to her at the inaugural conference for the Catalan Society of Clinical Pharmacy seminar. The thesis of her speech: "Too much medicine for the well and not enough for the sick" seemed very much to the point, therefore I decided to read her book; and I must say that I liked it so much that if I was an editor, I would order a Spanish translation right now.

What is the paradox that Dr. McCartney refers to? 

This paradox is no more or less than the thesis of her speech in Barcelona. If one is sick one must be persistent in order to receive the appropriate care (booking an appointment with the family doctor, limiting oneself to a little timeframe to explain what's wrong, putting up with long waiting lists to receive specialty care, etc). But if one is well, then the situation is reversed and the risk of overacting prevails, such as that in a screening or a health review, one is placed in the patient’s or in the pre-patient books thus occupying the position of a patient at risk and therefore, to receive preventative treatments for pathologies that may never occur or to be treated to combat a disease that one does not have.

Can health community work be of any use?

Great @nytimes article on need for community health workers #CHWs featuring my colleague @prabhjotsinghNY... http://t.co/wShbXqQl46

— Leana Wen, M.D. (@DrLeanaWen) 29 agost, 2014

Dr. Leana Wen, the chosen tweet author and author of the book "When doctors don’t listen", warns her followers that Tina Rosenberg has published an article in the New York Times about what Community Health Workers in the US do. After reading Rosenberg’s article, I thought that this tweet was not a good choice for our readers, as the American reality is a lot different from ours (in Spain). They have a much messier model and therefore they need low cost professionals who can lend a helping hand; in short, poorly paid quasi-volunteers working for charities helping the management of issues such as medication and habits of people living in poverty.

Hospital dependent patients: new cataloguing

In an article published in the New England Journal of Medicine, "Goal Oriented Patient Care," Dr. David Reuben, a geriatric doctor of Ronald Reagan UCLA Medical Center, proposed cataloguing the concept of "hospital dependent patient" such as those patients who a generation before were doomed to die quickly but now, thanks to the combined effectiveness of well coordinated professional teams and availability of technology, their life can be saved but they are unable to return to the previous clinical situation and therefore they enter a state of hospital dependence caused by the same clinical performance that saved their lives. Essentially, we’re not talking about a new disease entity, since most of these patients coincide with the group of chronic complex and/or frail elderly patients.

According to Dr. Reuben, "hospital dependent patients" once hospitalized, can get temporary stabilization, and even an acceptable quality of life, provided they have intensive nurse care, specialists guard teams and adequate resources availability and technological monitoring.

How to spot a "hospital dependent patient"?

Hospital dependent patients’ clinical problems are labile, unstable and unmanageable in the community and, for this reason, their hospitalizations are not avoidable, and herein lies the interest of Dr. Reuben’s cataloguing work.

In contrast, clinical targets for "standard complex chronic patients" focus on community services. These are patients that, if the system is able to offer intense enough programs tailored to their needs, in theory, could avoid hospital readmissions which should be understood as system failures.