JAMA

doi: 10.1001/jama.299.22.2599pmid: N/A

St John's Wort for Children With ADHD Children with attention-deficit/hyperactivity disorder (ADHD) are often treated effectively with stimulant medications. However, some parents prefer alternative therapies. In a randomized, double-blind, placebo-controlled, 8-week trial, Weber and colleagues Article investigated the efficacy and safety of Hypericum perforatum (St John's wort; 300 mg 3 times daily) for the treatment of children and adolescents with ADHD. The authors report that H perforatum was no better than placebo in reducing the severity of ADHD symptoms, and the frequency of adverse events was similar in both groups. In an editorial, Chan Article discusses patients' increasing use of complementary and alternative therapies and comments on efforts to improve the quality of research assessing the efficacy and safety of these therapies. Effects of Bright Light and Melatonin in the Elderly Circadian rhythm disturbances have been associated with cognitive decline and mood, behavioral, and sleep disturbances that affect many elderly persons with dementia. In a randomized trial of residents of elder care facilities in the Netherlands, Riemersma-van der Lek and colleagues investigated whether bright light and melatonin—known circadian system synchronizers—might ameliorate these symptoms of dementia. Care facilities were randomly assigned to either daily bright light or dim light, and study participants were randomly assigned to an evening dose of melatonin or placebo. The authors found that whole-day bright light was associated with modest improvements in cognitive and noncognitive symptoms of dementia. Melatonin was associated with improvements in sleep onset and duration but was associated with adverse effects on mood unless administered in conjunction with bright light. Article QRS in Patients With Worsening Heart Failure Electrical dyssynchrony, defined as a QRS duration of 120 milliseconds (ms) or greater, is associated with increased mortality in outpatients with heart failure. To assess the predictive value of the QRS duration in patients hospitalized for heart failure, Wang and colleagues retrospectively analyzed data from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial. The authors report that during a median follow-up of 9.9 months, all-cause mortality and a composite of cardiovascular death or rehospitalization for heart failure were higher in patients whose QRS duration at enrollment in EVEREST was prolonged (≥ 120 ms) compared with patients with a normal QRS duration (< 120 ms) at enrollment. Article CLINICIAN'S CORNER Chemotherapy at the End of Life Perspectives on Care at the Close of Life Mr L was a 56-year-old businessman who was diagnosed with stage IV lung cancer with brain and bone metastases. He was treated with brain and spinal radiation and 3 courses of systemic chemotherapy and lived for 14 months after diagnosis. Palliative intrathecal chemotherapy was administered until 6 days before his death. Harrington and Smith discuss the appropriate use of chemotherapy at the end of life and the importance of effective coordination of oncology and palliative care. Article A Piece of My Mind “Should I mar the identity of this complex person with such a rich life and legacy by reducing her to a medical diagnosis at the end—when, really, it was just genug?” From “Genug Syndrome.” Article Medical News & Perspectives Aging in America is explored in articles on how the US health care system is ill prepared to deliver geriatric care to an aging population Article, on projections that emergency departments may be strained by increasing numbers of visits by older adults Article, and on programs that are tackling the challenge of bringing physician-based care to homebound seniors Article. Commentaries Complexities of the physician workforce equation Article Biofilms and chronic infections Article Author in the Room Teleconference Join Wendie Berg, MD, PhD, June 18 from 2 to 3 PM eastern time to discuss screening women at high risk of breast cancer with mammography plus ultrasound vs mammography alone. To register, go to http://www.ihi.org/AuthorintheRoom. Readers Respond How would you manage a 70-year-old man with severe coronary and peripheral artery disease who presents with acute-onset slurred speech and left facial droop? Go to www.jama.com, read the case, and submit your response, which may be selected for online publication. Submission deadline is June 25. JAMA Patient Page For your patients: Information about cancer chemotherapy. Article

Southgate, M. Therese

doi: 10.1001/jama.299.22.2603pmid: 18544713

The year was 1929 and for most Americans the future did not bode well, though many—least of all the economists, it seemed—did not realize it at the time. Until then the decade immediately following the end of World War I had been America's most prosperous. Industrial production was at its highest level and so was consumption. Americans bought almost half the automobiles they produced. Unemployment was nearly nonexistent. Average wages exceeded $100 a month, reaching $1250 annually. Words like “flapper,” “jazz,” and “Model A” populated the lingua franca. And then, suddenly, one day in late October, as the decade neared its close, the movie ended. The last reel of extravaganza had run itself out and the good times went dark. The only light remaining was whatever hope people could muster by whatever means they had. Edward Hopper (1882-1967) spent the summer of 1929 on the coast of Maine, just as he had for the past several years. As usual, it was a productive summer; besides several watercolors, he completed three oils, one of which turned out to be his favorite, The Lighthouse at Two Lights (cover) . He was 47, married for the past five years to fellow painter Josephine Verstille Nivison, and already had a work in the permanent collection of the Museum of Modern Art in New York. Edward Hopper (1882-1967), The Lighthouse at Two Lights, 1929, American. Oil on canvas. 74.9 × 109.9 cm. Courtesy of The Metropolitan Museum of Art (http://www.metmuseum.org/home.asp), New York, New York; Hugo Kastor Fund, 1962 (62.95). Image ©The Metropolitan Museum of Art. Like Winslow Homer (JAMAcover, June 4, 2008), Hopper had begun as a commercial artist, working first for an advertising agency in New York City and later as an illustrator for magazines such as Scribner’s and Adventure. He studied with William Merrit Chase (whose teaching he later said he had to “unlearn”), Kenneth Hayes Miller (whom he liked), and Robert Henri (his favorite). He began spending summers in New England in 1910 and exhibited in the Armory Show in New York in 1913. His paintings need no signature: if a woman clutching her purse and wearing a hat sits alone in a Pullman compartment on a train, or if a woman stripped down to her slip sits before an open window in a barren room enjoying the evening breeze; if a man sits on the curb of an empty street on a Sunday morning, or if an elderly man rakes leaves in his yard on a waning October day, it is a Hopper. The unifying feature of these paintings is not, however, the isolated figure in each, no matter how strikingly lonely each might seem; it is rather the way Hopper creates his figures out of light, as though he were etching them on the air. Light, palpable light, light given shape and form is the true subject of the works. This is true not only for his oils, but for his watercolors and for his etchings as well. It is in the last modality that he was particularly adept at expressing the dialogue that exists between light and dark. Like Homer, Hopper was a man of few words but many pictures. He was also a patient man, a true observer. Like his Swiss contemporary, Paul Klee, and the silent man from Aix-en-Provence, Paul Cézanne, Hopper was careful never to impose his self on the subject he was painting. He did not go out and capture his motif; he remained still and received the motif. He did not force the motif to speak; he waited until it was ready and then he listened. It is thus that his paintings survive not as pretty “calendar pictures,” but as real objects expressing the fullness of their state of being. Such is the mystery of The Lighthouse at Two Lights. The surface image is obvious enough: a sandy dune, some scrubby flora, a tall, majestic lighthouse, low-rise housing for coast-guard personnel, the ubiquitous outhouse, and a sky—except for a few sea-blown clouds—clear as sapphire and deep as the soul of the universe. The clouds will sail on, of course, the sky will darken, but the lighthouse on its rocky promontory will endure forever. Like hope.

Wayne, Jane O.

doi: 10.1001/jama.299.22.2604pmid: N/A

A smile of recognition, a brief exchange.       And seated only a few feet from the TV, she resumes watching some old movie in black and white—film noir,       and no one I recognize. She’ll answer questions right through whatever plot's unfolding on the screen,       but most of her thoughts are out of order—a hand of cards that needs arranging into suits. Fact or fancy?       And which is which? So I do the talking. And she peers out absently, a reader stuck on a paragraph,       back and forth over the same sentences—the whole time her fingers busy on her lap, knitting       without yarn, and the room we're in growing smaller. Still I talk, though there's no tug at the other end       of the rope and by now I’ve used up the safe topics: food, weather, the new chair in the corner.       On the bedside table, last week’s roses sag in a clear vase of murky water, and the book-lined shelves are more wall now       than reading matter. The air is dry. My throat, too. Only twenty minutes—and I’m out of words,       slipping back into one of those moments on a stopped train where I watch the train beside me       start to move—though all along it's the one I’m on that's moving.

Soyke, Jennifer M.

doi: 10.1001/jama.299.22.2606pmid: 18544714

I was called to the home in the morning, but couldn't make it there until after office hours. Lisa waited for me, not because she needed me, but perhaps because she knew her family did. They who had lovingly cared for this lady at home for more than eight years attended her. Her rabbi had come to sit with her. A friend had brought a homeopathic remedy to aid her swallowing. “Ah, I see where we are,” I said, entering the room. Lisa sat quietly in her fancy candy-apple-red wheelchair, draped in colorful shawls and blankets, her breathing noisy in her throat but her face peaceful. She was on her way. The family and I talked about the potential difference in perceptions between our discomfort and her discomfort. A few drops of morphine, then later more homeopathic drops were gently placed under her tongue. We sat around her telling stories of her life, and of family and friends, addressing her in the conversation in the same way she’d always been included, even after she could no longer speak. When we noticed that there was no further noise of breathing, and her face was still, she was surrounded with their arms and their kisses and told that she could go or she could stay—her choice. They sang to her. She looked patrician, elevated and transported, and was gone. The following day I came by the house after a group of family and friends had spent hours writing Lisa's obituary together. When faced with the question of her actual cause of death, they realized we hadn't discussed it. So this group of people who loved her decided she had died of genug syndrome. In one of Lisa's languages, Yiddish, genug means “Enough!” or, commonly, “Enough, already!” “So what did she actually die of?” one family member asked. Her daughter stopped me, protesting that it wasn't important to know. She didn't want her mother's life to be summed up as a medical diagnosis. This vibrant lady, once a champion Austrian figure skater in 1936, a survivor of the Holocaust, and a teacher of hundreds of skaters, was a beloved wife for 50 years and a mother of two children who remember her as astonishingly indulgent and positive. I thought about how she gradually lost functions while still serving as an inspiring and dignified mother figure to a community of family and friends; how attentively she was cared for by a well-orchestrated group of family, friends, and paid caregivers who also became devoted to her; how she always recognized those she loved even when so many other neurological functions failed. Should I mar the identity of this complex person with such a rich life and legacy by reducing her to a medical diagnosis at the end—when, really, it was just genug? When end-of-life care transcends the medical model to be truly a natural part of life, as this family had achieved, listing a medical-model cause of death seemed incongruent with her whole life and spirit. “Well, actually,” I said, “you're right. She did die of genug syndrome.” If we as a society are to change the way we look at death, to see death as a natural end point to life, it will be helpful to recognize the existence of genug syndrome. While death so often falls into the medical realm, hospice has well established that there are excellent alternatives to the medical model of caring for patients at the end of life, in which the patient and family retain control of the dying process with minimal intervention from physicians. We can extend that end-of-life model to the description of the cause of death and resist the need to describe unique individuals, in the end, by the names of their disease processes. This doesn't prevent us from providing necessary epidemiologic data to our state public health departments. A recent obituary in Eugene, Oregon, listed “the common form of Zahl Kam Rauf ” as a cause of death. I’m told that's German for “number came up.” Clearly it's not only my patient Lisa's family that resists a medical summation of a rich life. At the funeral, I signed the death certificate. Cause of death: respiratory arrest secondary to genug syndrome. Back to top Article Information Acknowledgment: Thanks to Elisabeth “Lisa” Koenig Sygall, Susan Sygall, and Tom Broeker for the gift of participating in Lisa's care and to the inspired family and friends who recognized genug syndrome .

Voelker, Rebecca

doi: 10.1001/jama.299.22.2611pmid: 18544715

Thirty years after its first call for expanded geriatrics training, the Institute of Medicine (IOM) has issued a more urgent warning. In a new report, the IOM cautions that the US health care system is poorly equipped to care for unprecedented numbers of older US adults who will flood the system in just a few years. Geriatrician John Rowe, MD, chair of the IOM committee that produced Retooling for an Aging America: Building the Health Care Workforce, said the report addresses workforce problems that threaten the delivery of quality care to elderly patients even if the Medicare hospital insurance trust fund were adequately funded. “There is a sense that if we can fix [Medicare funding], we're going to be okay,” said Rowe, also a professor of health policy and management at the Columbia University Mailman School of Public Health in New York City. “That is one-half of the problem. Even if there is enough money, there isn't going to be anybody there to provide the care. We need to fix both halves of the problem, and we’ve been in denial up until now about the second half.” Demand vs supply The report offers a detailed description of how the demand for health care services for older adults will clash with the ability to supply those services in the next 2 decades. Currently, individuals aged 65 years or older comprise about 12% of the US population. By 2030, that figure is projected to increase to 20%. In actual numbers, the US population of individuals aged 65 years or older will nearly double, increasing from 37 million in 2005 to more than 70 million in 2030. Currently, said Rowe, the 12% of the population older than 65 years accounts for 26% of physician office visits, 35% of hospitalizations, and 34% of all prescriptions written. “When we double the number of elderly and we increase the proportion from 12% to 20%, it would follow that geriatric care is going to dominate health care in the United States,” he noted. As the population ages, the number of board-certified geriatricians has dropped in recent years. “The supply side is really scary,” said Rowe. The report indicates that in 2007, there were 7128 geriatricians and 1596 geriatric psychiatrists practicing in the United States. The figure for geriatricians represents a 22% decrease from 2000. Additionally, fewer than 1% of nurses, pharmacists, and physician assistants specialize in geriatrics and fewer than 4% of social workers are geriatrics specialists. To meet the demand for services for elderly patients by 2030, when the mid-range of baby boomers turns 75 years, an estimated 36 000 board-certified geriatricians will be needed in the United States, the report notes. But in 2006-2007, of 468 first-year geriatric medicine fellowships available, only 253 were filled. After examining data and talking with numerous experts, Rowe said, the committee “came to strong conclusions” that immediate action is needed in 3 main areas: increasing the competency of the entire health care workforce in basic care for older individuals; increasing the number of geriatric specialists; and changing the way that geriatric care is organized and delivered. The report also calls for public, private, and community organizations to help prepare family members and friends of elderly patients to assist with home care and to feel they are part of their loved one's care team. A number of organizations, including the American Geriatrics Society, the Association of American Medical Colleges (AAMC), and the American Society for Clinical Oncology, already have released studies or developed initiatives to address the need for more physicians who are adequately trained in the care of geriatric patients. But experts noted that the IOM's analysis is more comprehensive. “This report is much broader in its specifications for the entire workforce,” said Christopher Callahan, MD, director of the Indiana University Center for Aging Research, part of the Regenstrief Institute Inc, in Indianapolis. “It is looking all the way from family caregivers to professional direct care workers to social workers to physicians.” Basic competency The report recommends that all health care workers be required to demonstrate basic competence in caring for older patients to become licensed and certified. Currently, training for such direct-care workers as nursing aides and home health aides is skills based, said Susan Chapman, PhD, RN, assistant professor and director of Allied Health Workforce Studies at the University of California, San Francisco, Center for the Health Professions. Many of those skills focus on transferring—moving patients in and out of bed and to and from the bathroom. But Chapman, who was on the IOM committee that compiled the report, said training also should address common geriatric health conditions, including decline in memory, decreased mobility, and impaired vision and hearing. Another IOM committee member, Carol Raphael, MPA, president and chief executive officer of the Visiting Nurse Service of New York in New York City, said training for direct-care workers also should prepare them to recognize how balance problems or medication interactions may make elderly patients vulnerable to falls. The report recommends that the minimum federal training requirement for direct-care workers should be increased from 75 hours to at least 120 hours. Training recommendations for physicians take on a different dimension. The report notes that 98% of medical schools require “geriatric exposure” in their curricula and that private organizations, including the Donald W. Reynolds Foundation and the John A. Hartford Foundation, have provided tens of millions of dollars for enhanced geriatrics training. But despite such improvements, geriatrics courses may occur too infrequently and too late in training to attract physicians to the specialty. The report calls for medical students and resident physicians to care for elderly patients not just in hospitals and clinics, but also in nursing homes, patients' own homes, or assisted living facilities. M. Brownell Anderson, MEd, senior associate vice president in the Division of Medical Education at the AAMC, described how some medical schools integrate geriatrics education throughout the curriculum. “In pharmacology, they have [patients] come in with baggies of medications that they will take that day and discuss drug-drug interactions and prescribing [medications] to people who have to get up in the middle of the night to take a pill, or can't handle a small pill,” she explained. Anderson also noted that at least 40 US medical schools have senior mentor programs in which students interact with patients aged 65 years or older to observe not just how aging influences illness but also how many older patients maintain active, vital lives. “This gets away from the notion that geriatrics equals nursing homes,” she added. John Murphy, MD, president of the American Geriatrics Society, noted that geriatricians report the highest job satisfaction of all physician specialists. “It is very fulfilling, and we need to show that to medical students and residents,” said Murphy, also a professor of medicine and family medicine at Brown University School of Medicine, Providence, RI. But the report notes that income is a major disincentive for physicians to enter geriatrics. On average, geriatricians earned $163 000 a year in 2005 while internists earned $175 000; dermatologists may earn upward of $300 000. “Geriatrics is the only training fellowship that residents go into where they have the opportunity to earn less than prior to going into that fellowship,” said Murphy. Registered nurses and direct-care workers also face economic disincentives. The report urges Medicare to increase reimbursement rates for the services geriatrics specialists deliver and advises states to help raise direct-care workers' wages by directing funds to Medicaid payments that cover many of their services. State and federal programs for loan forgiveness and scholarships also are needed. The report recommends establishment of a National Geriatric Service Corps, modeled after the National Health Service Corps, which encourages physicians to practice in rural areas. Model care The report also discusses sweeping changes in the delivery of care that can improve the quality of care for older patients and reduce costs. A number of innovative care delivery models are described in the report, including a home-based geriatric care program and another that creates a home-like culture rather than a nursing home environment for older residents. Callahan of Indiana University was not a member of the IOM report committee, but he was involved in 2 of the models the report discusses, including the home-based program, Geriatric Resources for Assessment and Care of Elders, or GRACE. “The science has changed over the past 30 years,” he said. “There's a lot more known about care models and a lot more is known about the deficiencies in the health care system.” The models emphasize collaborative care involving physicians, nurses, social workers, and direct-care workers. Callahan said primary care physicians sometimes have expressed frustration in caring for elderly patients, particularly those with dementia or Alzheimer disease, because it appeared that no effective treatment was available. “That was one of the motivations of these collaborative care models, to say let's prove that if people had access to these models, it would make a difference,” he explained. “We’ve gotten past that now; it's no longer acceptable to say there's nothing I can do because nothing works. These models work; there is something we can do.” The report supports dissemination of effective models and recommends enhanced reimbursement for their use. But many are in place only in research settings. “The problem is, the day the grant ends the program stops,” said Rowe. “The funds are not available in an ongoing way to keep these teams funded and keep them together.” Callahan agreed that financing mechanisms must change to bolster the collaborative models and improve care. “It's time to take a step forward,” he said.

Hampton, Tracy

doi: 10.1001/jama.299.22.2613pmid: 18544716

Emergency departments are well-accustomed to seeing patients across the entire age spectrum, but more and more individuals aged 65 years or older are now seeking care in that setting. Experts say the situation could lead to increased overcrowding and compromised care for all patients. “Continuing the trend for elderly patients over the next few years could cause the emergency care system to collapse,” said Mary Pat McKay, MD, of the George Washington University Medical Center in Washington, DC. McKay and colleagues recently reported statistics indicating that visits by patients aged 65 to 74 years increased 34% from 1993 to 2003 (Roberts DC et al. Ann Emerg Med. 10.1016/j.annemergmed [published online ahead of print December 5, 2007]), the greatest increase among all age groups. The Centers for Disease Control and Prevention also has reported disproportionate increases in rates of emergency department visits among individuals aged 65 years or older. (Photo credit: A[[nbsp]]J Photos/www.sciencesource.com) The increasing numbers of older individuals seeking care in emergency departments could have negative effects on health care. Other researchers and clinicians are sounding similar alarms and are advocating for policy changes to address the issue. “We have a crisis on our hands in this country,” said Linda Lawrence, MD, president of the American College of Emergency Physicians. “Our emergency departments need some resuscitation.” Elderly visits The disproportionate increase in emergency department visits among seniors could have various effects on health care, given that older patients have longer lengths of stay in the emergency department and constitute an increasing proportion of the US population. Also, “these patients tend to be sicker and are more likely to be admitted from the emergency department to the hospital, but with many hospitals running a deficit of inpatient beds, I don't see where these patients are going to go,” said McKay. McKay and colleagues set out to assess the situation by documenting who among the elderly are visiting emergency departments the most and by investigating the nature of these visits. Using 1993 to 2003 data from the National Hospital Ambulatory Medical Care Survey, an annual national sample of visits to the emergency departments of nonfederal general and short-stay hospitals, the researchers found that overall visits among individuals aged 65 to 74 years increased by a third and that visit rates for blacks in this age group nearly doubled. The authors estimate that this increase among blacks translates to 77 visits per 100 population per year. The visit rates for whites increased 26%, to 36 visits per 100. The study revealed that the number of visits at which 3 or more medications were prescribed increased 44%. The investigators noted that the mean admission rate (approximately 33%) for the elderly did not change significantly during the study period, meaning the absolute number of hospital admissions increased. These findings suggest that the additional emergency department visits in recent years were not for frivolous reasons and were no less urgent than those in previous years. Therefore, the increased rates among older individuals appear to reflect an increase in legitimate emergency problems, rather than increased visits for convenience or because of lack of access to nonemergency care. “Many of their visits are well justified, and it's just something that we're going to need to expect—as more people age, there will be more emergency department visits and admissions,” said Lawrence. Consequences for all patients While an increase in visits among seniors is already apparent, experts say that the baby boom has yet to have its full impact on emergency departments. If the trends found in McKay's study continue, US emergency department visits by individuals aged 65 to 74 years could nearly double, from 6.4 million visits to 11.7 million visits by 2013. Emergency departments are already struggling with overcrowding, lack of funds, and an increase in visits by uninsured patients. Add to that the anticipated influx of baby boomers who will experience various chronic conditions and acute injuries, and the quality of care is likely to be affected considerably, according to Lawrence. “Studies are showing that all patients in the emergency department are less likely to get timely pain medicines, patients with heart attacks are waiting longer to be seen, and patients getting antibiotics are delayed in receiving those critical medications,” she said. Seeing more elderly patients in emergency departments can mean less productivity for hospital staff. Often, older individuals need more attention, and their presenting symptoms often are not as straightforward as in younger patients. “Older people don't present with diseases in the same ways that we're taught in medical school,” said Carmel Bitondo Dyer, MD, director of the Geriatric Medicine Division at the University of Texas Medical School in Houston. For example, compared with their younger counterparts, older patients with pneumonia are less likely to have the typical hallmarks of fever and elevated white blood cell counts, and those with myocardial infarction are less likely to have chest pain, said Dyer. “You have to do more investigative work and more diagnostic testing to get to the answer for older people,” she said. In addition, the prevalence of cognitive impairment is high in elderly patients presenting in the emergency department, which can make communication difficult. To prepare for the years ahead, health care professionals must understand why an increasing proportion of older individuals are visiting emergency departments. Experts have some hypotheses, but they admit that more research in this area is needed. Some say that because of advances in medical care and longer life spans, more patients have chronic medical issues that can lead to emergency complications. But this is unlikely to be the sole reason. Dyer noted that older individuals may have difficulty finding a physician because some no longer accept Medicare. Also, seniors now often take numerous medications, making it more likely that adverse drug events will arise that warrant a visit to the emergency department. Regardless of the cause, the increasing rates of emergency department visits by older patients may mean that some elderly individuals are receiving less than optimal care. One review found that while older patients have distinct medical needs, the current model of emergency care does not adequately provide the complex care required for frail older patients (Aminzadeh F, Dalziel WB. Ann Emerg Med. 2002;39[3]:238-247). Potential solutions Dyer suggests that appropriate screening and intervention protocols be developed to ensure effective treatment of elderly patients in emergency departments. She and others also note that steps should be taken to reduce the need for emergency services through primary and secondary prevention, through such measures as better community services for older adults, improved education by pharmacists, and continuous relationships with primary care physicians. These and other steps could also help ease the demands of elderly care outside of emergency departments. A recent report by the Institute of Medicine cautions that aging baby boomers will face a health care work force that is too small and is unprepared to meet their specific health needs. The report says there is a shortage of health care workers in geriatric care because the field attracts fewer specialists than other disciplines and experiences high turnover rates among direct-care workers such as nurse aides. The report urges higher pay and Medicare reimbursement rates for the services of geriatric specialists. In addition, all clinicians should be competent in geriatric care, and family members and other informal caregivers should be considered an integral part of the health care team and should be given tools to provide assistance. These measures could help improve the quality of care that elderly individuals receive across the board—at home, in hospital clinics, and in emergency departments. Dyer also recommended that emergency departments find better ways to communicate with primary care physicians, who can provide important information about individual patients when they seek emergency care. To address the issue system-wide, the American College of Emergency Physicians has drafted the Access to Emergency Services Act of 2007, a bill that is now in both the House and Senate (http://www.acep.org/advocacy.aspx?id=21642). This act has 3 main components: it creates a commission that will examine factors—such as emergency department crowding, the availability of on-call specialists, and medical liability issues—that affect delivery of emergency medical services; it authorizes funding through Medicare to physicians who provide emergency-related care; and it calls on the Centers for Medicare & Medicaid Services to study emergency department boarding and to develop guidelines and create incentives to alleviate this problem. Lawrence urges physicians to get in touch with their senators and representatives to show their support for the act. The American College of Emergency Physicians also is working with local hospitals and emergency departments to come up with temporary solutions until larger efforts can improve the situation. “What we see in our emergency departments is reflective of our failing health care system in this country, and physicians all believe that there needs to be some real reform,” said Lawrence.

Friedrich, M. J.

doi: 10.1001/jama.299.22.2618pmid: 18544717

For Eric Hardt, MD, another “day at the office” often takes place outside the walls of his workplace, in a gritty Boston neighborhood. Today, he's in one such neighborhood, to make home visits to 4 elderly patients who would have great difficulty getting to the clinic at Boston Medical Center. Hardt grabs his bag and heads to his first appointment. The patient, a lively woman in her 90s, still lives in the same neat and inviting apartment she moved into decades earlier but became a home care patient a few years ago when forgetfulness—the first sign of early dementia—stopped her from coming into the clinic. Before he begins her examination, Hardt banters back and forth with the patient and her friend, a woman from the neighborhood who regularly looks in on the elderly woman. (Photo credit: Ana Blohm, MD/The Mount Sinai Hospital) A physician from the Mount Sinai Visiting Doctors Program in New York City examines one of her patients at the latter's home. Hardt determines that the patient has lost weight recently, and her blood pressure is sky-high. A quick “kitchen biopsy” reveals little food in the refrigerator and an unopened bottle of blood pressure pills. Her recent dietary and medication lapses signal the advance of dementia, notes Hardt. The neighbor has brought some protein shakes, and these, together with a daily pill dispenser, can help address these problems and keep Hardt's patient in her home for now. Another member of the home care team will be by in a few days to check on the woman and follow up on Hardt's orders. Meanwhile, he's off to his next house call a few blocks away. A doctor in the house Hardt has worked in this neighborhood for 24 years as part of Boston University (BU) School of Medicine's Home Care Program, administered through Boston Medical Center. Hardt is clinical director of the program, which was established in the 1870s and is the oldest continuously functioning physician home visiting program in the country. “On home visits we get better data about functional status, compliance with meds, the family situation, and we're more efficient in implementing plans,” said Hardt. “We think it's easier to understand and manage the conditions of our patients when we see them at home than if we saw them in the clinic.” The house call program takes a team approach to caring for patients. Six attending physicians, along with several nurse case managers and nurse practitioners, make house calls. About 3 or 4 geriatric fellows also make home visits as part of their training. There is a strong educational component to BU's house call program, which introduces virtually all BU medical students as well as many residents to home care. The house call program is part of a continuum of geriatric care that includes an office practice and nursing home and hospice care, all overseen by Hardt. This allows coordinated care of patients in all settings, notes David Kornetsky, administrative director of BU's Geriatric Services. There are at least 2 million homebound seniors in the United States (Levine SA et al. JAMA. 2003;290[9]:1203-1207). As the population ages, the number of homebound elders with multiple chronic conditions will increase, and so will the need for physician-based home care. The Boston program is one of a number of house call programs associated with academic medical centers around the country that contain clinical service and educational components. Each has grown organically from the needs of patients as well as the circumstances and personalities at these institutions. Retooling for a new age Physician-based home care is certainly not a new phenomenon but rather the retooling of an old practice for a new age. It's a type of care that patients say they prefer. For example, Bruce Leff, MD, associate professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and associate director of Hopkins' Elder House Call Program, reported that a model of home care he and his colleagues designed, called Hospital at Home, was associated with greater satisfaction for patients and their family members compared with acute hospital inpatient care (Leff B et al. J Am Geriatr Soc. 2006;54[9]:1355-1363). Similarly, at the Mount Sinai Visiting Doctors Program in New York City, more than 50% of patients who die while being cared for in the program die in their homes, according to their wishes, vs 20%, which was the average for people in the United States in the late 1990s (Flory J et al. Health Aff [Millwood]. 2004;23[3]:194-200). The Mount Sinai program is the largest academic-based home visit program in the country and serves more than 1000 patients in East Harlem, said Theresa Soriano, MD, PhD, director of the program. The 12 clinicians in the program make more than 5000 visits every year to patients older than 18 years throughout most of Manhattan. The program was founded in 1995 by three internal medicine residents at the Mount Sinai Hospital (Smith KL et al. J Am Geriatr Soc. 2006;54[8]:1283-1289). According to David Muller, MD, dean of medicine at Mount Sinai School of Medicine and one of the founders, seeing patients at home was a way to “humanize” the residency training experience, which can be grueling for both residents and patients. Boston University's program, one of the few in the country at the time, provided a place to learn about setting up a house call program for the frail and elderly. But the residents received their first instruction in how to make home visits from the Little Sisters of the Assumption, an order of nuns who are all nurses. Having provided home care in East Harlem for more than 60 years, the sisters knew that many of their patients had no access to a physician, said Muller. “The incredible irony was that the majority of these patients were right here in the community, maybe even across the street from the medical school,” said Muller. Efficient care An important part of home visits is an environmental and safety assessment. Eliminating risks for falling, arranging for repair to a dilapidated building, or getting electricity turned back on can be just as important as medical care to the health of the patient, said Soriano. “Sometimes it becomes our role to advocate for these changes even though it's not a medical issue,” she said. As she pointed out, making sure a patient with diabetes takes insulin is a moot point if the refrigerator doesn't work to keep the drug chilled. George Taler, MD, director of the Medical House Call Program at the Washington Hospital Center in Washington, DC, would agree. In his early days of practicing geriatric medicine, Taler said, he might do a fine job medically of treating his patients with multiple chronic conditions in the office, but he rarely had the opportunity to discuss their care with their caregivers or to see what hurdles they needed to overcome to receive the needed care. This lack made it difficult for him to see if his recommendations for what needed to be done for his patients outside the office were feasible or achievable. House calls just seemed a much better way of taking care of these very ill patients, he said. Taler admits that when he began this work, he thought this approach was less efficient than an office-based practice because of travel time and time spent talking to caregivers. “But now I’ve changed my tune,” he said. Several recent studies have recognized the cost savings and the potential for improved care through physician house call programs (Leff B et al. Ann Intern Med. 2005;143[11]:798-808; and studies presented at an April 2006 meeting at George Washington University, Upending the Triangle [http://www.aahcp.org]). “As it turns out, house calls are an extraordinarily efficient way of practicing medicine, as long as the bottom line is controlling the health of the population under your care,” said Taler. The challenge, he said, is to combine the two goals of excellent patient care and cost-effectiveness. Independence at home Meeting this challenge is something that Taler and other house call physicians have been working on for some time. Their work has manifested as a legislative proposal called Independence at Home that is currently making its way into Congress. The concept focuses on a small but expensive segment of the over-65 population. “Two thirds of Medicare spending is for people with 5 or more chronic conditions, who represent roughly 10% of the Medicare population,” said Taler, referring to a Congressional Budget Office report based on 2005 data from the Centers for Medicare & Medicaid Services. “This new legislation creates systems that can meet the needs of these patients, and it is financially sustaining,” he added. Peter Boling, MD, director of long-term care and geriatrics at Virginia Commonwealth University, Medical College of Virginia, Richmond, and director of Virginia Commonwealth's House Calls Program, also has worked on this legislation. He noted that one of its goals is to draw more and better people into the field by providing financial incentives. “Right now, medical students who we train in making house calls look at what I do and think it's lovely, but they're coming out of medical school with a lot of debt, and they're sensitive to price,” said Boling. “If they're going to work hard to take care of the chronically ill, they need to have an incentive to do so.” Another goal is to create a system of care that allows physicians to care for patients across transitions and to be able to track them when they need to go into other settings of care. “This legislation really speaks to all of what we do as house call physicians, including that which is less obvious than home visits,” said Rebecca Conant, MD, assistant clinical professor of geriatrics and director of the Housecalls Program at the University of California, San Francisco. She pointed out that much skill and time are required to coordinate the services needed to keep frail elders at home and, when a patient does go into the hospital or nursing home, to smooth those transitions. “None of this is recognized or compensated under our current system,” she said. “It's only by managing these patients in a very holistic way, by maintaining relationships with caregivers, by trying to provide great care in the least expensive venues when appropriate, that we’ll have any hope of providing the right kind of chronic disease management while containing costs for this small but expensive group of patients,” said Hopkins' Leff.

Mitka, Mike

doi: 10.1001/jama.299.22.2620-bpmid: N/A

Cutbacks in federal money to public and teaching hospitals threaten the ability of the nation's emergency departments to respond to surges of casualties from terrorist attacks or natural disasters, said Rep Henry A. Waxman (D, Calif), chairman of the House Committee on Oversight and Government Reform. (Photo credit: Michael Donne/www.sciencesource.com) Some legislators say cuts in Medicaid funding will compromise the ability of hospitals to handle a patient surge following a catastrophe. During a 2-day hearing in early May, committee members heard testimony about the problem, resulting from 3 Medicaid regulations issued by the Department of Health and Human Services (DHHS) that will reduce federal funds to public and teaching hospitals by billions of dollars over the next 5 years. “Why would the Department of Health and Human Services, knowing that the nation's emergency care system is already stretched to the breaking point, withdraw billions of federal dollars from the hospitals that provide the most comprehensive emergency care to the most seriously injured?” asked Waxman. DHHS Secretary Michael O. Leavitt, testified his agency is overseeing several programs addressing emergency preparedness and that the issued Medicaid regulations are intended to ensure that federal money goes to appropriate Medicaid health care services and that states pay their fair share.

Mitka, Mike

doi: 10.1001/jama.299.22.2620-dpmid: N/A

Members of the House Subcommittee on Oversight and Investigations (part of the Committee on Energy and Commerce) heard testimony on May 8 to help them determine whether legislation to limit or eliminate direct-to-consumer advertising of prescription drugs is needed. At the hearing, Nancy Nielsen, MD, president-elect of the American Medical Association, called for better federal oversight of such advertisements. “Direct-to-consumer ads often portray drugs through rose-colored glasses by including more information about a drug's benefits than risks,” said Nielsen in a press release. “Imbalances in these ads can diminish patient understanding of certain drug risks and increase the need for an ongoing dialogue between patients and physicians about the benefits and risks of prescription drugs.”

Mitka, Mike

doi: 10.1001/jama.299.22.2620-cpmid: N/A

Two Democratic House leaders argue that health savings accounts (HSAs) are used more as tax shelters by wealthy people than as a tool for lower-income families to obtain affordable health care coverage. The accusations were based on a Government Accountability Office report (http://www.gao.gov/new.items/d08474r.pdf) that found the average adjusted gross income of HSA enrollees was about $139 000 compared with $57 000 for those without HSAs. The report also said the total value of all HSA contributions reported to the Internal Revenue Service in 2005 was $754 million while withdrawals totaled $366 million, suggesting the accounts serve more as a tax shelter than a vehicle to make health care more affordable. The report, released April 30, was compiled at the request of Rep Henry A. Waxman (D, Calif), chairman of the House Committee on Oversight and Government Reform, and Rep Pete Stark (D, Calif), chairman of the Ways and Means Health Subcommittee. Both men also are backing a bill, HR 5719 (http://www.thomas.gov), requiring HSA enrollees to substantiate that HSA withdrawals are used for allowable medical expenses. They said some data show HSA funds have been spent by individuals on non–health-related expenses, including escort services and casinos.