Asserting that the prevailing model for palliative care of the elderly is fundamentally flawed and ill-suited for older patients suffering from slowly progressive chronic illness, four researchers from the University of California Davis School of Medicine have proposed a new framework for palliative care - the TLC model. The new model is named for its five defining characteristics - timely, team-oriented, longitudinal, collaborative and comprehensive.
The authors submit that palliative care in older patients should not be viewed as synonymous with hospice or end-of-life care; rather, it should be viewed as care primarily intended to relieve the burden of physical and emotional suffering that often accompany illnesses associated with aging. Further, they suggest that palliative care should be a major focus of care throughout the aging process, regardless of whether death is imminent.
The proposed model for palliative care for the elderly has five core characteristics: 1) Timely - care should be proactive rather than reactive to avoid prolonged and unnecessary suffering; 2) Team-oriented - health care team members, such as nurses and trained lay persons, should play a major role in supporting family self-care efforts and implementing palliative care; 3) Longitudinal - care should be provided at all points along the disease trajectory, with an evolving balance of palliative and curative treatments; 4) Collaborative - care and decision making should be a shared enterprise among physicians, patients and their loved ones; and 5) Comprehensive - care should be informed by comprehensive geriatric assessment research literature.
In an effort to evaluate the efficacy of the TLC model, the researchers recently tested the new model at two assisted living facilities in the Sacramento, Calif., area. Preliminary findings provide initial support for the TLC model as a promising framework for better meeting the palliative care needs of older patients.
The TLC Model of Palliative Care in the Elderly: Preliminary Application in the Assisted Living Setting
By Anthony F. Jerant, M.D., et al
Implementation of Medicaid Managed Care in New Mexico Associated with Decreased Immunization Rates
Contrary to expectation, the implementation of Medicaid managed care in New Mexico was associated with significantly decreased immunization coverage for the 4:3:1 childhood vaccination series. According to data from the National Immunization Survey, following the policy change, vaccination rates fell from 80 percent in 1996 to 73 percent in 2001, among the lowest in the nation.
Although the researchers could not fully determine the causal impact of Medicaid managed care, their findings suggest that the new policy played a significant role in initiating complex systems-level changes associated with declining immunizations. The study findings point to a number of conditions that might have contributed to the decreased immunization coverage: 1) a reduction in funding to state-run public health clinics where many of the most vulnerable patients received their care, and difficulty gaining access to Medicaid managed care providers; 2) increased informal referrals by private physicians and managed care organizations to community health centers and state-run public health clinics; and 3) increased workloads and delays at community health centers linked partly to the informal referrals for immunizations.
Based on New Mexico's experience with Medicaid managed care, the authors caution policy makers about the unanticipated and adverse consequences that seemingly narrow policy changes can have on complex systems. They advise policy makers to consider the direct and indirect effects of Medicaid reform on safety net institutions responsible for immunizations and other necessary preventive services.
Immunization Coverage and Medicaid Managed Care in New Mexico: A Multimethod Assessment
Michael A. Schillaci, Ph.D., et al
Adult Childhood Cancer Survivors Contact with Medical System Decreases with Age Despite Increased Risk of Long-Term Health Problems Related to Cancer Therapy
Studies show that long-term survivors of childhood cancer face considerable risk for mortality, morbidity and adverse health status resulting from their previous cancer therapy and can benefit from early diagnosis and intervention or preventive care targeted at reducing risk for late effects. However, a study by Oeffinger and colleagues finds that survivors reported a decrease in contact with the medical system just when the incidence of many late effects are increasing.
In a study of 9,434 adult childhood cancer survivors, the researchers found that while almost 90 percent of the survivors reported some contact with a health care clinician in a 2-year period, the likelihood of reporting a cancer-related visit or a general physician examination decreased significantly as the survivor aged or the time interval from cancer diagnosis increased. The authors note that the decrease in medical visits occurred at a stage in life when the incidence of many late effects of cancer therapy, including most second cancers, cardiovascular disease, osteoperosis and endocrinopathies, are increasing.
The authors suggest that these findings have important implications for cancer centers and primary care physicians, who provide health care for most of this growing high-risk population. To optimize risk-based care of this vulnerable population, they recommend the development of interventions aimed at educating survivors, enhancing their transition to primary care physicians and fostering ongoing communication between survivors, cancer centers and primary care physicians.
Health Care of Young Adult Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study
By Kevin C. Oeffinger, M.D., et al
Teaching Hospitals in Dire Straits
Teaching hospitals, which serve an important role as the classrooms for physicians, nurses and other health care providers, realized deep cuts in profitability between 1996 and 1999 in part to due to the Balanced Budget Act of 1997, which included the largest cuts in the history of Medicare, an important financial cushion for teaching hospitals and graduate medical education.
According to an analysis conducted by researchers at the Robert Graham Center, during this time period, mean total margins for all teaching hospitals fell more than 50 percent, except for family practice single-residency hospitals for which margins fell 21 percent. More than one third of teaching hospitals operated in the red. Despite having better margins, the authors point out that the proportion of family practice single-residency hospitals operating with negative total margins nearly tripled. They add that during this period, overall Medicare margins remained relatively stable, however graduate medical education margins fell by nearly 24 percent and Medicare + Choice graduate medical education payments were 90 percent less than baseline projections. Taken together, these findings suggest that while the financial health of teaching hospitals was undoubtedly affected by the Balanced Budget Act of 1997, other forces contributed as much or more.
These figures, they warn, paint a grim future for teaching hospitals, which also are faced with new patient safety mandates, increasing pressure to improve resident work environments and hours, rising malpractice premiums and other rising health care costs. The authors call for more transparency from the Medicare Payment Advisory Commission, which has a critical role in evaluating the effects of Medicare policy changes.
The Balanced Budget Act of 1997 and the Financial Health of Teaching Hospitals
Robert L. Phillips, Jr., M.D., M.S.P.H., et al
OTHER STUDIES IN THIS ISSUE:
Diabetic Patients Who Smoke: Are They Different? by Leif I. Solberg, M.D., et al
Relative to nonsmokers, diabetic patients who smoke are more likely to report often feeling depressed and are less likely to be active in self-care or comply with diabetes care recommendations.
Is Making Smoking Status a Vital Sign Sufficient to Increase Cessation Support Actions in Clinical Practice? by Raymond Boyle, Ph.D., et al
Making smoking a vital sign does not increase the likelihood that clinicians will offer more cessation support for smokers.
Physician Attitudes and Beliefs Associated with Patient Pneumococcal Polysaccharide Vaccination Status by Tammy A. Santibanez, Ph.D., et al
Study identifies a number of barriers to vaccination for pneumococcal disease, one of the leading causes of death in the elderly.
A Cost-Benefit Analysis of Testing for Influenza A in High-Risk Adults by William J. Hueston, M.D., et al
There is a need for different clinical approaches when treating influenza depending on the probability that a patient has influenza and which antiviral drug will be used for treatment.
Religion, Spirituality, and Health Status in Geriatric Outpatients
by Timothy P. Daaleman, D.O., et al
Older adults who describe themselves as "spiritual" but not "religious" are more likely to appraise their health as good.
Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Practice, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the North American Primary Care Research Group. The journal is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, www.annfammed.org.