Developing Standards ‘Of, By, And For’ Older Adults: Reflections On Patricia Gabow’s Narrative Matters Essay

Imagine three people: a healthy 30-year-old, a 60-year-old with high blood pressure, diabetes and arthritis, and a 90-year-old who is frail and has dementia advanced to the point where her speech often doesn’t make sense.

If I lined them up, any doctor could instantly tell me which was which.

Ditto if each broke a bone and I showed the physicians only their x-rays.

And if I asked the clinicians to predict each patient’s risk of complications and adverse events based on nothing more than the few words above, they would again rapidly and reliably make accurate assessments.

Yet, for the most part, our health system lumps these three people into a single “adult” category, an approach that flies in the face of anatomy, physiology, pharmacodynamics, risk stratification, and a whole lot more, including common sense, population trends, ethics, economics, and epidemiology.

As CEO and chief medical officer of a large safety net health system, Patricia Gabow, author of the powerful Narrative Matters essay in the May 2015 issue of Health Affairs, introduced evidence-based standard care pathways, computerized order entry and order sets, and Toyota’s “Lean” principles, which led to marked improvements in quality of care and health outcomes in patient populations for whom health disparities have been longstanding challenges. Such methods are now being adopted across the country and incentivized by the Affordable Care Act.

Then her mother, a nonagenarian with frailty and advanced dementia, injured herself in a fall. Gabow realized she didn’t want her mother to receive standard care. She successfully advocated for care better suited to their situation, and her mother was soon released from her surgeon’s care and lived the remaining two months of her life in relative comfort.

Since the vast majority of Americans lack Gabow’s training, clout, and connections, the only way to ensure all older Americans get similar high quality care is to create standards and policies that acknowledge what we all already know: older adults differ from younger adults in ways that matter.

Precedents In Medicine And Health Policy

I began medical school in 1988. At that time, we learned to care for a single patient: the 70-kilogram man. He was healthy until given the diseases we had to diagnose and treat, and it went without saying that he was neither young nor old, and Caucasian. This educational scenario paralleled clinical research where subjects were also male, white, and middle-aged. The reasoning behind this approach was that women were obviously different than men, and blacks different than whites, so adding in these complications polluted the science.

While clean study samples worked well in laboratory settings, they proved counterproductive in medical education, research, and care. Excluding large segments of the population from standards because of their differences, and then applying those standards to them despite their differences, often resulted in poor care and outcomes. The civil rights and feminist movements of the 1960s and 1970s led to investigations of the impact of this approach on care and outcomes in the 1980s and brought new educational strategies and federal research policies in the 1990s.

Interestingly, this was not the first time medicine acknowledged that differences matter. In the 1800s, hospitals—first in Europe and then in the United States—were founded for the exclusive care of children. We still have pediatric hospitals and clinicians today. We understand that children differ from adults: they require different doses of medications, respond differently to some treatments, have conditions unique to their age group, and have additional developmental, social, and family needs that significantly impact their care and outcomes.

The same is true of older adults. Now it’s time to apply the same logic to their care as we already apply to the care of children, women, and minorities.

An Action Plan for Health Policy

Transforming health care to better serve older patients must begin with the development and application of standards of care that consider age-related changes in physiology and risk, patients’ health status—based on co-morbidities, functional abilities or disability, and overall prognosis—as well as life priorities. In this approach, age is necessary but not sufficient to determine good care; the care that will benefit an 82-year-old who exercises daily, travels, and volunteers may not help, and might harm, a 73-year-old with significant heart disease who is wheelchair bound and dependent from a stroke.

Policy makers can take three key steps to move American medicine away from its failed one-size-fits-all approach for adult care. First, they must require care pathways and outcome metrics “of, by, and for” older adults when certifying health systems and hospitals. Second, medical education oversight bodies such as the Liaison Committee on Medical Education and Accreditation Council for Graduate Medical Education must begin requiring training in the care of older adults analogous to the training these bodies already require in the care of children and women. Third, the National Institutes of Health and other funders must add older adults to the categories of subjects to be included in trials, or justify their exclusion, just as they have done for women, children, and minorities.

Standards For Life’s Third Act

Patricia Gabow’s experience with her mother gives us clues into some of what these new standards might look like:

1. They would focus more on the person and their health, and less on the affected organ or disease process. Gabow’s mother’s dementia meant that a c-spine collar and IV would have caused agitation that would have led to distress and possibly more harm to her body than that already sustained in the fall.
2. They would skip tests that would not change the treatment plan. Gabow explains that her mother’s head trauma notwithstanding, there was no head CT finding on which their family would act.
3. They would prioritize care that maximized wellbeing and independence. While Gabow’s mother initially balked at having the cut on her forearm sutured, a local anesthetic enabled the wound to be closed so it would be more comfortable and easier to care for going forward.
4. They would base all diagnostic and treatment decisions on the patient’s goals of care and support the family in doing the same. Gabow had to advocate against the system and many of its providers for care in keeping with her mother’s wishes and happiness, a situation that added to Gabow’s stress and anxiety.
5. They would consider not only the pros and cons of acute management but the downstream risks and benefits of treatments. When a “simple fix” of her mother’s hip fracture was recommended, Gabow alone seems to have imagined the future in which the hip was repaired but her mother was terrified in a foreign setting, strapped down, and subject to invasive attentions she didn’t want, all of which would “seem like torture to her.”

By creating a care pathway appropriate to her mother’s frailty, dementia, goals, and values, Patricia Gabow not only saved her mother’s life (perhaps literally, and certainly figuratively), she also saved our health system approximately $156,000. It was a win-win, but older adults shouldn’t need to have raised a physician-CEO to get that standard of care.

SOURCE: Health Affairs Blog – Read entire story here.