How to make healthy and wise descisions

1. Choosing Wisely in
Healthcare
Makes you healthy wealthy and wise.
Aboo Nasar, M.D., MPH, MBA
Medical Director Revive Rejuvenation Center, La Jolla

2. Talking Points
• 47 Million Americans 1/6 under age 65 has no health insurance
• Unpaid medical bills leading cause of personal bankruptcy
• Clinton Administration health care reform
• 2006 Healthcare cost $2.1 Trillion according to CMS 2016 $4.1 Trillion or 20%
GDP
• Life expectancy is 77 years just matching with Costa Rica, Chile
• Infant mortality rate behind Cuba
• 1/3rd of cost Administrative. Canada 16%
• It’s the Price Stupid. High administrative cost, malpractice, labor

3. Talking Points
• Average cost per day in US Hospital is $1,666
• 1/3rd to 1/5th in waste that equals to 500-700 Billion
• 1/3rd of medicine is unnecessary that leads to increase cost
• Eradication of small pox, Vaccines, Antibiotics, Nutrition, Organ Transplant
• National Survey 34% Americans believe any disease is curable with Modern
Medicine
• Cutting edge technology High tech CT, MRI, PET Scans have given us the
extra eye
• Unnecessary care 30,000 lives a year

4. • 1990 Evidence based Medicine concepts
• 1980 there were 600,00 physicians
• More doctors means more procedures
• Patients and doctors attracted to specialized care
• Medicare cost per capita $500 in 1965 to $5000 in 1995
• In 1996 Miami cost Medicare $8,414 in Minneapolis $3,341
• Last 6 months of their life highest spending region spent $14,644 to
$9,074 in lowest spending regions
• Elliott Fisher in 2000 published study showing Medicare recipients in
higher cost areas were not better off health wise
• Had increased risk of mortality
• I. Infection
• C. Complications
• E. Errors

5. • Wennberg quoted " Medical license is like a hunting license. They go out and find
enough patients to bag their limit, and their limit is set by some income target"
• " Surgical signature persists over time like a cultural transmission .like from Tampa
to Fort Myers FL back surgery up by 60%
• MI, Colorectal Cancer and Hip fracture followed for 2 yrs
• Dr. Donald Berwick published study in Annals of Internal Medicine. Highest
spending regions received 60% more care than lowest spending regions. Highest
spending areas patients were 2-6% more likely to die than least spending areas.
• IOM Report To Err is Human 98,000 deaths from medication errors. Another 90-400
K patients are harmed or killed by incorrect use of drug
• Institute of Medicine IOM 1999 report 4% of 33 Million hospital admissions that is
1.3 Million complications a year. 1/3 errors are actual negligence.
• Hospital based errors are the 8th leading cause of death.
• ADR 90,000 to 400,000
• Human Error authored by UK Psychologist James Reason complex system that
depends upon everyone body doing everything right all the time are inevitably
faced with "latent errors" accidents just waiting to happen.
• Atul Gandhi Complications, " Stakes are high, the liberties taken tremendous "

6. Fishers Paradox
• Medicare patients with the same well defined medical conditions, the same
chances of survival, and even the same socio economic status are most likely to die
in parts of the country which spends the highest Medicare dollars. Spending more
means doing more increases the chance of errors and patients hit with
complication. More days a patient stays in hospital more complex treatment he
receives the higher likelihood of adverse events.
• High spending Hospitals 75% of patients with MI received ASA
• Low spending area hospitals 83% sent home with baby ASA
• High spending hospitals 48% received flu vaccines
• Low spending hospitals 60% received flu vaccines
• Primary care physicians met better quality health indicators and less mortality rates
•
• 2003 NEJM. RAND Corporation looked at 439 Quality Indicators by Elizabeth
McGlynn
• Patients received recommended care 55% time
• Cataracts corrected 80%
• DM had appropriate test done 24%
• 1/5 patients with COPD advised to quit smoking, 1/10 received counseling

7. A Tale of Two Cities
• LA had 2.5 times more ICU beds per capita compared to Rochester Minnesota
home of Mayo Clinic
• Roemer’s Law is " A built hospital bed is a filled hospital bed"
• Boston Massachusetts 3,000 beds,
• Yale in New Haven Connecticut 978 beds
• Elderly spent 40% more time in Boston vs New Haven and 40% more likely to be
admitted to hospital
• Los Angeles elder is likely to spend 11 days in ICU vs 3.3 days in San Francisco
• Los Angeles 50 ICU beds per 1000 Medicare beneficiaries
• San Francisco 12 ICU beds per 1000 Medicare beneficiaries
• Los Angeles Medicare beneficiary $104,000 in the last 2 yrs of life and 23 days in
hospital
• San Francisco Medicare beneficiary spent $57,000 in last 2 yrs of life and 11 days in
hospital

8. Drug Disease Burden in Elderly
• Average US Senior is on 14+ drugs and medications
• 8 or more medications elevates risk for ADR by 100%
• Lower education level higher probability of 3+ psychotropics.
• Chairman of Geriatrics at Harvard Medical School, “ Any new Geriatric Syndrome
is an adverse drug reaction unless proven otherwise”
• 27% of ADE in primary care and 42% in LTC were preventable
• 2000/2001 Medical Expenditure Panel Survey PIM was $7.2 Billion
• List of PIM was published by Beers in 1991
• Non pharmacologic approach is considered superior, “ less is more approach”
• IDT approach is paramount
• Older adults are largest consumers but they are often underrepresented in clinical
trials.

9. PTSD
• P Procedures Feeding Tubes, Foley Caths
• T Tests Lipid Panels, U/A,
• S Screenings/Surveillance SSIC, PSA, PAPs
• D Smart Drugs, Antipsychotics, Statins

10. Antipsychotics and Dementia: A Time
for Restraint
Objectives:
• Estimate mortality risk associated with commonly prescribed antipsychotics
by Rebecca Rossom, et al.
Design: 5 year retrospective study.
Setting: Veteran National Healthcare Data
Participants: predominantly male, 65 years or older with diagnosis of dementia
and no other indication of antipsychotic drugs.
End Point: mortality.

11. Conclusion: Commonly prescribed doses of Haldol, Olanzapine, and
Risperidone, but not quietapine, increase 30 day mortality risk.
Results in first 30 days
Haloperidol n
= 2217 dose: 1
mg OR: 3.2
Olanzapine n
= 3384 Dose:
2.5 mg OR: 1.5
Quietapine n
= 4277 Dose: >
50 mg OR: 1.2
Risperidone n
= 8245 Dose: 1
mg OR: 1.6

12. Discussion
• No FDA approval for treatment for
behavioral symptoms.
• 60% of the VA patients were prescribed
antipsychotics, and 20% had organic
brain syndrome.
• 2005 FDA offered black box warning
(JAGS: Vol 58 June 2010).

13. • Design: population based case control study.
• Setting: U.S. general practice research database (GPRD).
• Participants: dementia with age > 65 years.
• Measurements:
• OR of CVA users vs. non users.
• Users of typical vs. atypical antipsychotics.
• Results: Adjusting confounding variables OR on CVA.
• Typical vs. no antipsychotics: 1.16
• Atypical vs. no antipsychotics: 0.62
• Conclusion: Typical antipsychotics increases the risk for CVA and the risk abates
when drugs are discontinued.

14. ADAMS Study: Aging demographics
and memory study (2002 – 2004)
• Study design: Retrospective cohort study
• Assess dementia severity
• Frequency of psychotropics
• Antipsychotics: 19.1 %
• Antidepressants: 29.1%
• Anticonvulsants: 8.8%
• Benzodiazepines: 9.8%
• 307 ADAMS participants:
• Alzheimers: 69.3%
• Vascular dementia: 17.7%
• Others 12.4%
• Findings:
• Older adults with dementia likely psychotropic use OR = 7.4
• Older adults with dementia having caregivers OR = 0.19

15. Drug-Disease Interaction: Beers Criteria
(AGS 2012 Beers Criteria, Vol 63 Jan 2015)
• Study Design: Cross-sectional study
• Settings: 15 VA community living centers
• Participants: 65 or older, with diagnosis of dementia/MCI
• History of falls, hip fracture, heart failure, PUD, CKD stage 4-5.
• Measurements: Drug-disease interaction (DDI)
• Results: 361/696 or 51.9% DDI (1 or more)
• 540 residents with dementia with DDI, antipsychotics use: 35.4%, benzodiazepines
:14.9%
• 267/696 or 67.8%.
• 50.7% who took psychoactive medications, antipsychotic use: 30.7%, SSRI 33.1%,
Anticonvulsants 25.1%

16. Regulation Agencies Impact on
Prescription Practice
• OBRA Act 87 studied on 485 bed nursing home
• Design: 12 month retrospective cohort study with review
of medications and view administrative records and
pharmacy recommendations.
• 75% of the times attempt was made to discontinue the
drugs.

17. Strategy: Reducing Antipsychotic Drugs
(SHELTER Study: Services in Health for Elderly
LTC)
• Public health policy needs to dictate decreased use of antipsychotics.
• There is no LTA recommendation for use.
• Antidepressants only if non-pharmacological measures fail (data limited).
• Algorithms: DICE
• Describe
• Investigate
• Create
• Evaluate
• Sudden changes in living condition triggers agitated behavior.
• Transitioning to adult daycare programs
• Discussion: Emotional support to patients and caregivers.
• Creative engagement program/Psychosocial activities

18. Strategy: Reducing Antipsychotic Drugs
(SHELTER Study: Services in Health for Elderly
LTC)
• Pan European INTERDEM/psychosocial intervention in 179 randomized
control trials review.
• Cognitive training and stimulation, exercise, music, reminiscence, massage,
and recreational therapy.
• Aggressive agitation stems from personal care.
• Person-centered care DVD on (eg. bathing without battle).
• Primary goal: Holistic model of well-being for patients, families and
caregivers (reduced caregiver burden).

19. Famous Business Quotes in Health care
• Henry Gadsden CEO of Merck told Fortune Magazine that he
wanted Merck to be more like chewing gum maker
Wrigley’s.” It is long to be my dream to make drugs for
healthy people so that Merck could sell to everyone”. Today
Gadsden’s dream is the major driver behind this mammoth
half a trillion drug making industry.
• Dr. Walter Willett, Professor of Epidemiology and Nutrition at
Harvard School of Public Health said” Drug companies are
extremely powerful. They put huge efforts into promoting the
benefits of these drugs. Its easier for everyone to go in this
direction. There’s no huge industry promoting smoking
cessation or healthy food”

20. Cholesterol, Statins and Longevity from Age
70-90 Years Jerusalem Longitudinal Study
• Cholesterol as a risk factor among elderly Is highly controversial
• Role of statins is also controversial
• All cause mortality data studied
• Survival was increased with Cholesterol>200mg/dl vs <200mg/dl
• Survival increased among subjects treated with statins mostly in the 80 yr range category.
• Jeremy Jacobs et al

21. PROSPER Study Prospective Study of Pravastatin in
Elderly at Risk of Vascular disease
• Evaluate the study of Pravastatin in older adults with known Vascular
disease or prevalent CV Risk factors, enrolled 5,804 patients aged
70-82 and f/u 3 years
• Pravastatin reduced the primary endpoint of CV death by 15%
• No history of CAD no reduced risk of CAD or Stroke
• No effect on all cause mortality
• Increase risk of developing cancer. By 4 years 1 extra case of
cancer for every 100 people taking a statin drug

22. Heart Protection Study
• Randomized 20,536 high risk individuals
• 5,806 were aged 70-80
• Simvastatin 40 mg/day vs placebo
• F/U period 5 yrs
• 17.8% reduction in fatal or non fatal vascular events aged
75-80

23. JUPITER Justification for the Use of Statins in Primary
Prevention, An Intervention Trial Evaluating
Rosuvastatin
• 5,695 patients aged 70 and older( mean age 74) with LDL-C<130
mg/dl, HS-CRP of 2 mg/L or greater and no prior history of CV
disease
• Rosuvastatin was associated with 39% reduction in primary
composite endpoint of first CV event, hospitalizations for USA, but
the absolute benefit was small, and the Number Needed to Treat
NNT for 1 year to prevent 1 event was 130 individuals $$$237K
• Rosuvastatin had no significant effect on all-cause mortality

24. AMDA Statement on Lipid
management in Elderly
• There is no evidence that Hypercholesterolemia or low
HDL is an important risk factor for all cause mortality,
coronary heart disease mortality, hospitalization for MI or
Unstable Angina in person older than 70 yrs. In fact,
studies show that elderly patients with lower cholesterol
have the highest mortality after adjusting other risk
factors. In addition, a less favorable risk-benefit ratio
may be seen in patients older than 85, where benefit
may be more diminished and risks from statin drugs
more increased ( cognitive impairment, falls,
neuropathy and muscle damage

25. Cholesterol Myth and Statin Dilemma
• Cholesterol and its role in Neuro transmitters, Sex hormone
• Sexual dysfunction on men by 50%
• Framingham Heart Study published in Archives of Internal
Medicine in 1993 shows higher total cholesterol correlates
with death from CVD only through age 60
• Risk of death from causes other than CAD increases with
lower Total Cholesterol after they reach 50
• Lack of Physical Activity is highly correlated with overall
mortality

26. Framingham Heart Study
• Author concludes:” Physicians should be
cautious about initiating cholesterol lowering
medications above 65-70 yrs of age
• Archives of Internal Medicine in 1999” None of
the lipid measures was associated with the risk
of MI in this population aged 65 and older”

27. 4S and LIPID Studies and CARE Studies
• Treatment with statins significantly reduced the incidence of future
MI, CAD Mortality and overall Mortality
• CARE Study average LDL 139mg/dl significant decrease in risk of
heart disease but no significant decrease in risk of death from heart
disease or overall mortality risk
• 4S Study treatment with statin in women overall mortality 12% higher
compared to placebo
• CARE Study statins in women reduces risk of heart disease but not
overall mortality
• LIPID Study failed to show protection in women

28. ALLHAT Study The Antihypertensive and Lipid
Lowering Treatment to Prevent Heart Attack Trial
• Tripling the number of people on statins neither prevented CAD nor
decreased overall mortality.
• It applies not for people age 55 to 65, with or without Diabetes, with or
without heart disease and not for LDL Cholesterol higher or lower than 130.
The only group that benefited are the African Americans who had fewer
episodes of heart disease but no fewer deaths.
• Dr. Richard Pasternak Cardiologist who wrote the editorial in JAMA
concluded, “ Physicians might be tempted to conclude that this large study
demonstrates that statins do not work; how ever it is well known they do” He
is one of the 14 authors of the NCEP Cholesterol guidelines.
• http://www.nhbli.nih.gov/guidelines/cholesterol/atp3upd04_disclose.htm
• accessed Nov,16,2004)

29. When to obtain urine cultures.
• Asymptomatic Bacteriuria: To treat or not to treat.
• Objectives: prevalence of asymptomatic bacteriuria patients
• Settings: Hem Shohen Center
• Urine cultures obtained and second cultures obtained after one week if initial cultures show 10/5 CFU/mL.
• Subjects were followed up after one year
• Asymptomatic bacteriuria repeat urine cultures every 2 months.
• Results:
• 85/196 or 43.3% Asymptomatic bacteriuria
• More bedridden 91.7 % vs. 82.1%
• Dementia 78.8% vs. 59.8%
• Incontinence of bladder 93% vs. 71.4%
• 1 year prospective observation shows bacteriuria mortality rate is 25.9% vs. 7,1 % for non-bacteriuria
• Increased functional impairment has increased mortality risk
• Increased mortality is not attributable to urinary infection.

30. Asymptomatic Bacteriuria in Elderly
Male JAGS Nov 1990
• Prospective Longitudinal Study Ambulatory men followed for
1 to 4.5 years
• Prevalence of CIB was 12%
• Gram +ve organism
• 29 men with bacteriuria and 105 non bacteriuric patients
followed with serial urine cultures
• Spontaneous resolution 22/29 or 76%
• Bacterial persistence 38%
• Bacterial Treatment no benefits

31. Asymptomatic Bacteriuria in Older
Ambulatory Women JAGS Mar 1996
• Study Design- Controlled Clinical Trial
• Objectives- Determine whether treatment of asymptomatic bacteriuria in
older ambulatory women affects subsequent UTI
• Measurements- Urine cultures every 6 months
• Results- 23 initially culture positive participants receiving antibiotic
treatment for Asymptomatic bacteriuria 9/27 were culture +ve at 6 mos
contrast to 18/27 who received no treatment or placebo. However
symptoms of UTI were more common in Antibiotic treated group.
• Conclusion- Abx therapy reduced subsequent occurrence of +ve urine
cultures, but symptoms were not reduced. Based on the study of morbidity,
studies showing no reduction in mortality, complications of abx therapy and
its cost, treatment of asymptomatic bacteriuria in older women is
contraindicated.

32. When to obtain urine cultures.
• Septicemia 83/100,000 patients in 1979 and 240/100,000 in 2000.
• 65% of the cases are patients 65 years or older.
• Antibiotics do not improve outcomes related to morbidity and mortality.
• Increased risk for:
• Drug interactions
• Adverse drug reactions (ADRs)
• Colonization with resistant bacteria
• Geriatric syndromes with chronic incontinence, lethargy, anorexia, invasive infections (No relationship)
• 11/96 or 12% patients who received antibiotics for UTI developed C. difficile colitis 3 weeks post-treatment (Rot
Janapan et al.)
• Quinolone therapy for 6 months led to febrile UTI with quinolone resistant organisms 17.5%.
• Treatment with trimethoprim/sulfamethoxazole prophylaxis for one month on post-menopausal women increased
prevalence of resistant E. coli in stool from 20% to 85%.
• Even antibiotic treatment in asymptomatic bacteriuria in young women increased risk of subsequent UTI 3 times.
• Benign colonizers transform into virulent bacteria.
• Selection of resistant pathogens increase risk for fatal outcomes and healthcare costs.

33. CDC Report on Clostridium difficile
• USA Today reports that CDC published in NEJM nearly half a million
Americans suffer from life threatening C Difficile infections
• 29,000 deaths last year
• Number of infections doubled from 2000-2010
• “ C diff infections cause immense suffering and deaths for thousands
of Americans each year” CDC Director Tom Friedman
• Colectomy done because of permanent damage to colon, per
CDC Michael Bell
• 1/3 patients had outside of hospital but 80% of them visited OP
doctors or dentist office
• Fecal Transplant for recalcitrant diarrhea.

34. Reduction of antibiotics in asymptomatic
bacteriuria (Katherine Evans Feb 2014/AMDA)
• Objective: Decrease antibiotic use of UTI by 25%
• Setting: 4 SNFs
• Two practice algorithms developed based on published guidelines.
• Clinicians ordered UA and treatment of UTI based on algorithms.
• Not meeting UTI algorithm criteria nursing staff monitored for hydration and
nonspecific changes.
• With the change of urine color and composition resident behavior was monitored.
• Results:
• ¾ facilities had at least a 25% reduction
• Conclusion: Multifactorial interventions by facility MD, patient and family education,
decrease antibiotic initiation for asymptomatic bacteriuria by more than 25%.
Continued education and support is needed.

35. Sliding scale insulin coverage (SSIC) in
long-term diabetics
• Diabetes affects 18 million Americans.
• Diabetes prevalence in nursing homes is 15-18%.
• SSIC is a reactive way in treating diabetes, increases patients’
discomfort and nursing times.
• Potential to cause hyperglycemia/hypoglycemia
• Meals are erratic
• Basal insulin/Basal + rapidly acting insulin
• Dangers of hypoglycemia: falls and falls-related injuries and
hospitalization

36. AMDA Clinical practice guidelines for
elderly diabetics
• Individualized therapy in nursing home patients
• “Although intensive treatment to control blood glucose levels is shown to reduce
diabetic complications, such treatment may not be appropriate for all individuals in
a long-term care setting.”
• To maintain the highest quality of life consideration of therapeutic and diagnostic
mortalities must be taken into account.
• Cognitive and functional status
• Severity of the disease
• Coexisting medical conditions
• Express preference
• Life expectancy
• “Clinicians caring for older adults with diabetes must involve heterogeneity into
consideration in an institutional setting and privatizing treatment goals.

37. Wise man’s sayings:
• “As you ought not to attempt to care the eyes
without the head or the head without the body,
so neither ought to attempt to cure the body
without the soul. For the part will never be well
unless the whole is well.” Plato