Goldfeld et al describe the expenditures for Medicare services provided to a cohort of 323 nursing home residents who were followed up for 18 months. On average, health care expenditures were $2303 per 90 days of residence, with 30% of those expenditures due to hospitalizations and 46% for hospice services. The study identifies several modifiable factors associated with higher costs. Strategies that promote high-quality palliative care may be able to shift expenditures away from aggressive treatments for these patients at the end of life.
Using 2 national databases, the Nationwide Inpatient Sample and the Multiple Cause-of-Death Files from 1993 to 2006, Wiener et al examined epidemiologic trends in pulmonary embolism (PE) surrounding the introduction of highly sensitive computed tomographic pulmonary angiography (CTPA). In the 8 years following the introduction of CTPA, PE incidence almost doubled, case fatality decreased by a third, and PE mortality changed little (3% decrease). Meanwhile, more Americans are experiencing iatrogenic harm from treatment of pulmonary emboli (71% increase).
Given the national discussion on the size, scope, and potential influence of commercial support for continuing medical educa-tion (CME) activities, Tabas et al surveyed attendees at a series of live CME activities about CME funding, bias, and costs. Of the 770 respondents, the majority believed that commercial support introduces bias (88%), with greater amounts of support introducing greater risk of bias. Only 15%, however, supported elimination of commercial support from CME activities, and less than half (42%) were willing to pay increased registration fees to decrease or eliminate commercial support. Participants who perceived bias from commercial support were more likely (2- to 3-fold) to favor increased registration fees to decrease such support. Participants greatly underestimated the costs of ancillary activities such as food as well as the amount of commercial funding.
Billings and Krakauer describe how the patient-physician relationship has evolved in recent decades as more life-sustaining treatments have become available. They examine respect for patient autonomy and describe how patient autonomy can be promoted while the physician's responsibility for technical medical decisions is simultaneously affirmed. The patient is the expert on his or her values and goals, while the physician is the expert on the medical means for honoring the patient's perspective. The authors conclude that an intervention, such as cardiopulmonary resuscitation, should not be offered when, by the patient's own criteria, it promises no benefit or would be more harmful than beneficial.
All Medicare/Medicaid certified US nursing homes were tracked to document cumulative facility closures over a decade (1999-2008). Nationally, a total of 1776 or 11% of freestanding nursing homes closed compared with 1126 closures or nearly 50% of hospital-based facilities. Combined, there was a net loss of over 5% of all nursing facility beds during this period. At a more local level, nursing home closures were geographically concentrated in communities with higher proportions of blacks or Hispanics, and/or a higher poverty rate. Given the rapid increase in the size of minority elderly populations and the projected growth in their long-term care needs, these findings suggest that disparities in access to nursing facilities may increase.
Cumulative rate of nursing home closures by state, 1999 through 2008.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2011;171(9):799. doi:10.1001/archinternmed.2011.172