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Brain MRI performed in three individuals during the acute stage of encephalopathy showed bilateral T2-weighted hyperintensities of basal ganglia.1,2 In these three cases, follow-up brain MRI performed between 14 and 20 days afterwards showed disappearance or great improvement of the lesions. As in the current observation, all individuals recovered rapidly after metformin was discontinued. Although the exact pathophysiological mechanism remains unknown, an accumulation of metformin in the brain has been suggested.1,2 The fact that metformin is eliminated unchanged through the kidney could explain why symptoms occurred concomitantly with an increase in blood creatinine in the current observation. The lack of recurrent events without metformin, even though there were several subsequent episodes of high plasma creatinine, excluded that kidney failure could have induced encephalopathy, especially because the increase in creatinine was moderate. To conclude, because metformin is commonly prescribed in individuals with diabetes mellitus, clinicians should be aware that it can be a direct cause of encephalopathy. Yannick Bejot, MD, PhD Department of Neurology, University Hospital, Medical School of Dijon, University of Burgundy, Dijon, France Philip Bielefeld, MD Service de Medecine Interne et Maladies Systemiques, Centre Hospitalier Universitaire de Dijon, Dijon, France Anne-Laure Guiboux, PharmD Catherine Sgro, MD Service de Pharmacovigilance, Centre Hospitalier Universitaire de Dijon, Dijon, France Samer Janoura, MD Department of Neurology, University Hospital, Medical School of Dijon, University of Burgundy, Dijon, France Herve Devilliers, MD Jean-Francßois Besancenot, MD Service de Medecine Interne et Maladies Systemiques, Centre Hospitalier Universitaire de Dijon, Dijon, France Maurice Giroud, MD Department of Neurology, University Hospital, Medical School of Dijon, University of Burgundy, Dijon, France
ACKNOWLEDGEMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to the article by participating in concept and design, drafting the article or revising it critically for important intellectual content, and approving the final manuscript. All authors were involved in the individual’s treatment. Sponsor’s Role: No sponsor.
LETTERS TO THE EDITOR
621
REFERENCES 1. Jung EY, Cho HS, Seo JW et al. Metformin-induced encephalopathy without lactic acidosis in a patient with contraindication for metformin. Hemodial Int 2009;13:172–175. 2. Kang YJ, Bae EJ, Seo JW et al. Two additional cases of metformin-associated encephalopathy in patients with end-stage renal disease undergoing hemodialysis. Hemodial Int 2013;17:111–115. 3. Vander T, Hallevy H, Ifergane G et al. Metformin-induced encephalopathy without lactic acidosis. Diabet Med 2004;21:194–195.
COMMENTS/RESPONSES IMPROVING CARE FOR OLDER ADULTS WITH CHRONIC ILLNESSES AND FUNCTIONAL IMPAIRMENTS: A BROADER PERSPECTIVE To the Editor: Organization of health care in the community has become more and more complex. The longevity of people with chronic illnesses has increased significantly, they stay longer in the community, and treatment possibilities have increased. Fourteen percent of U.S. community residents had chronic conditions and functional limitations. This 14% accounts for 46% of all healthcare spending.1 High-quality care for chronic illness is characterized by productive interactions between primary care practice teams and patients that consistently provide the assessments, support for self-management, optimization of therapy, and follow-up associated with good outcomes.2 Close monitoring of the conditions of frail older people with chronic illnesses in their home environment, can prevent unnecessary exacerbations of their chronic illness by providing a link between care provided by physicians or other prescribing professionals and their self-care at home.3 The care of elderly people with chronic conditions and functional problems too often suffers from a lack of coordination and integration that results in poor outcomes and high costs. Of the hospitalizations of dually eligible individuals, 40% were deemed avoidable.4 With the high level of avoidable (re)hospitalizations, one would expect that cost-effective interventions should be possible. Many of the successful transitional care interventions targeting chronically ill adults shared similar features, such as assigning a nurse as the clinical manager or leader and including in-person home visits to people who have been discharged.5 Frequent in-person contact with patients, strong working relationships between coordinators and physicians, strong patient education programs using motivational interviewing or other behavior change tools, medication management programs, transitional care interventions, and care coordinators who acted as communication hubs were important program features of successful fee-for-service-based care coordination interventions.6 From the perspective of cost-effectiveness, the results are mixed at best.7 Targeting high-risk individuals is difficult, and organizations, teams, and professionals often lack the incentives to make (costly) changes. Provider reimbursements are based on encounters of short duration, which discourages the provision of time-consuming, but
622
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critical, activities such as patient education, counseling, and coordination of care between providers.8 Changes are not without (financial) risks and will only be implemented when, at the level of organizations and groups or teams, change will lead to (perceived) benefits. Protocols and working patterns of teams might have to change. Interventions to coordinate care often consist of activities on top of regular care, which makes the system even more complex, with more caregivers busy informing each other. New ways forward might have to be sought—ways in which additional caregivers are not relied on to coordinate care, but instead communication is improved within the system. The Independence at Home (IAH) concept consists of mobile teams of primary medical, nursing, and social work staff who deliver comprehensive primary care to the individual at home. IAH teams replace office-based providers for the small subgroup of ill elderly adults who are poorly served in the office setting. The teams offer access to care for sick homebound individuals who have little or inadequate ongoing primary medical care because of their immobility. This model of home-based primary care led to 17% lower total Medicare costs over a mean 2 years of follow-up, with similar mortality in the group that received home-based primary care and the control group.9 Another way is to expand the reach of the primary care physician (PCP) by using his or her connection with community nurses. One-third of frail older adults receive help with activities of daily living. In this case, the community nurse who visits individuals regularly in their homes might be able to monitor their health and discuss changes with the PCP. The nurse has many possibilities to gain the trust of clients and their social networks to change lifestyles. The education level of the nurse might need to be high to have good judgment of the risk of health deterioration, to convince clients and their social networks to improve self-management, adherence to medications and a healthy lifestyle, and to have a good relationship with the PCP (including adequate advising and answering questions). With the rise of the popularity of the medical home, the possibilities of care coordination by nurse and PCP within their regular working schedule might increase in the future. In the Netherlands, the fast-growing company Buurtzorg works successfully with a model of self-managed teams, with high satisfaction levels of nurses, clients, and PCPs.10 To increase the probability of success, blending payment of Medicaid and Medicare is recommended. States have limited (financial) incentives to invest in a more-generous Medicaid policy and integrate care for people with chronic diseases with long-term care. Peter Alders, PhD, MSc Ministry of Health, Welfare and Sport, The Hague, the Netherlands
ACKNOWLEDGMENTS I am grateful to Richard Frank for discussing the paper and Katie Dean for research support. The Commonwealth Fund provided support for this research. The views presented here are those of the author and should not be
MARCH 2015–VOL. 63, NO. 3
JAGS
attributed to The Commonwealth Fund or its directors, officers, or staff. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: The author was the sole contributor to this letter. Sponsor’s Role: Part of the research was done during a Harkness Fellowship at Harvard Medical School. The Commonwealth Fund funds the Harkness Fellowship.
REFERENCES 1. Alecxih L, Shen S, Chan I et al. Individuals Living in the Community with Chronic Conditions and Functional Limitations: A Closer Look. Washington, DC: Office of the Assistant Secretary for Planning & Evaluation, US Department of Health and Human Services, 2010. 2. Wagner EH, Austin BT, Davis C et al. Improving chronic illness care: Translating evidence into action. Health Aff 2001;20:64–78. 3. Marek KD, Popejoy L, Petroski G et al. Nurse care coordination in community-based long-term care. J Nurs Scholarsh 2006;38:80–86. 4. Walsh EG, Freiman M, Haber S et al. Cost Drivers for Dually Eligible Beneficiaries: Potentially Avoidable Hospitalizations from Nursing Facility, Skilled Nursing Facility, and Home and Community Based Services Waiver Programs. Waltham, MA: RTI International, 2010. 5. Naylor MD, Brooten DA, Campbell RL et al. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. J Am Geriatr Soc 2004;52:675–684. 6. Brown RS, Peikes D, Peterson G et al. Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff 2012;31:1156–1166. 7. Brown R, Mann D. Best bets for reducing Medicare costs for dual eligible beneficiaries: Assessing the evidence. No. 7574. Mathematica Policy Research, 2012. 8. Wolff JL, Boult C. Moving beyond round pegs and square holes: Restructuring Medicare to improve chronic care. Ann Intern Med 2005;143: 439–445. 9. DeJonge KE, Jamshed N, Gilden D et al. Effects of home-based primary care on Medicare costs in high-risk elders. J Am Geriatr Soc 2014;62:1825–1831. 10. De Veer AJ, Brandt HE, Schellevis FG et al. Buurtzorg: nieuw en toch vertrouwd. Een onderzoek naar de ervaringen van cliënten, mantelzorgers, medewerkers en huisartsen. [Care in the neighborhood. A study about experiences of clients, care staff and general practitioners involved]. Utrecht: Nivel, 2008.
THE PLAY OF CHANCE MAY, IN SOME CONTEXTS, BE CONSISTENT To the Editor: As long as there are elderly adults with nonvalvular atrial fibrillation (NVAF),1 there will be elderly adults with NVAF who have stroke attributable not to cardiogenic embolism but to coexisting stenotic cerebrovascular disease,2 simply because NVAF1 and nonembolic cerebral infarction (the latter a surrogate for stenotic cerebrovascular disease) are both age related.1,3 In one study, there was a positive correlation (correlation coefficient = 0.187, P < .001) between CHADS2 score (which was originally compiled to evaluate the risk of stroke attributable to cardiogenic embolism in NVAF) and number of arteries with concomitant atherosclerosis (severity ≥50%) in 780 consecutive individuals with NVAF of mean age 69.5 who had undergone angiographic studies at index stroke.2 Likewise, as long as there are women aged 60 and older with autoimmune hypothyroidism,4 there will be women
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
MARCH 2015–VOL. 63, NO. 3
Brain MRI performed in three individuals during the acute stage of encephalopathy showed bilateral T2-weighted hyperintensities of basal ganglia.1,2 In these three cases, follow-up brain MRI performed between 14 and 20 days afterwards showed disappearance or great improvement of the lesions. As in the current observation, all individuals recovered rapidly after metformin was discontinued. Although the exact pathophysiological mechanism remains unknown, an accumulation of metformin in the brain has been suggested.1,2 The fact that metformin is eliminated unchanged through the kidney could explain why symptoms occurred concomitantly with an increase in blood creatinine in the current observation. The lack of recurrent events without metformin, even though there were several subsequent episodes of high plasma creatinine, excluded that kidney failure could have induced encephalopathy, especially because the increase in creatinine was moderate. To conclude, because metformin is commonly prescribed in individuals with diabetes mellitus, clinicians should be aware that it can be a direct cause of encephalopathy. Yannick Bejot, MD, PhD Department of Neurology, University Hospital, Medical School of Dijon, University of Burgundy, Dijon, France Philip Bielefeld, MD Service de Medecine Interne et Maladies Systemiques, Centre Hospitalier Universitaire de Dijon, Dijon, France Anne-Laure Guiboux, PharmD Catherine Sgro, MD Service de Pharmacovigilance, Centre Hospitalier Universitaire de Dijon, Dijon, France Samer Janoura, MD Department of Neurology, University Hospital, Medical School of Dijon, University of Burgundy, Dijon, France Herve Devilliers, MD Jean-Francßois Besancenot, MD Service de Medecine Interne et Maladies Systemiques, Centre Hospitalier Universitaire de Dijon, Dijon, France Maurice Giroud, MD Department of Neurology, University Hospital, Medical School of Dijon, University of Burgundy, Dijon, France
ACKNOWLEDGEMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to the article by participating in concept and design, drafting the article or revising it critically for important intellectual content, and approving the final manuscript. All authors were involved in the individual’s treatment. Sponsor’s Role: No sponsor.
LETTERS TO THE EDITOR
621
REFERENCES 1. Jung EY, Cho HS, Seo JW et al. Metformin-induced encephalopathy without lactic acidosis in a patient with contraindication for metformin. Hemodial Int 2009;13:172–175. 2. Kang YJ, Bae EJ, Seo JW et al. Two additional cases of metformin-associated encephalopathy in patients with end-stage renal disease undergoing hemodialysis. Hemodial Int 2013;17:111–115. 3. Vander T, Hallevy H, Ifergane G et al. Metformin-induced encephalopathy without lactic acidosis. Diabet Med 2004;21:194–195.
COMMENTS/RESPONSES IMPROVING CARE FOR OLDER ADULTS WITH CHRONIC ILLNESSES AND FUNCTIONAL IMPAIRMENTS: A BROADER PERSPECTIVE To the Editor: Organization of health care in the community has become more and more complex. The longevity of people with chronic illnesses has increased significantly, they stay longer in the community, and treatment possibilities have increased. Fourteen percent of U.S. community residents had chronic conditions and functional limitations. This 14% accounts for 46% of all healthcare spending.1 High-quality care for chronic illness is characterized by productive interactions between primary care practice teams and patients that consistently provide the assessments, support for self-management, optimization of therapy, and follow-up associated with good outcomes.2 Close monitoring of the conditions of frail older people with chronic illnesses in their home environment, can prevent unnecessary exacerbations of their chronic illness by providing a link between care provided by physicians or other prescribing professionals and their self-care at home.3 The care of elderly people with chronic conditions and functional problems too often suffers from a lack of coordination and integration that results in poor outcomes and high costs. Of the hospitalizations of dually eligible individuals, 40% were deemed avoidable.4 With the high level of avoidable (re)hospitalizations, one would expect that cost-effective interventions should be possible. Many of the successful transitional care interventions targeting chronically ill adults shared similar features, such as assigning a nurse as the clinical manager or leader and including in-person home visits to people who have been discharged.5 Frequent in-person contact with patients, strong working relationships between coordinators and physicians, strong patient education programs using motivational interviewing or other behavior change tools, medication management programs, transitional care interventions, and care coordinators who acted as communication hubs were important program features of successful fee-for-service-based care coordination interventions.6 From the perspective of cost-effectiveness, the results are mixed at best.7 Targeting high-risk individuals is difficult, and organizations, teams, and professionals often lack the incentives to make (costly) changes. Provider reimbursements are based on encounters of short duration, which discourages the provision of time-consuming, but
622
LETTERS TO THE EDITOR
critical, activities such as patient education, counseling, and coordination of care between providers.8 Changes are not without (financial) risks and will only be implemented when, at the level of organizations and groups or teams, change will lead to (perceived) benefits. Protocols and working patterns of teams might have to change. Interventions to coordinate care often consist of activities on top of regular care, which makes the system even more complex, with more caregivers busy informing each other. New ways forward might have to be sought—ways in which additional caregivers are not relied on to coordinate care, but instead communication is improved within the system. The Independence at Home (IAH) concept consists of mobile teams of primary medical, nursing, and social work staff who deliver comprehensive primary care to the individual at home. IAH teams replace office-based providers for the small subgroup of ill elderly adults who are poorly served in the office setting. The teams offer access to care for sick homebound individuals who have little or inadequate ongoing primary medical care because of their immobility. This model of home-based primary care led to 17% lower total Medicare costs over a mean 2 years of follow-up, with similar mortality in the group that received home-based primary care and the control group.9 Another way is to expand the reach of the primary care physician (PCP) by using his or her connection with community nurses. One-third of frail older adults receive help with activities of daily living. In this case, the community nurse who visits individuals regularly in their homes might be able to monitor their health and discuss changes with the PCP. The nurse has many possibilities to gain the trust of clients and their social networks to change lifestyles. The education level of the nurse might need to be high to have good judgment of the risk of health deterioration, to convince clients and their social networks to improve self-management, adherence to medications and a healthy lifestyle, and to have a good relationship with the PCP (including adequate advising and answering questions). With the rise of the popularity of the medical home, the possibilities of care coordination by nurse and PCP within their regular working schedule might increase in the future. In the Netherlands, the fast-growing company Buurtzorg works successfully with a model of self-managed teams, with high satisfaction levels of nurses, clients, and PCPs.10 To increase the probability of success, blending payment of Medicaid and Medicare is recommended. States have limited (financial) incentives to invest in a more-generous Medicaid policy and integrate care for people with chronic diseases with long-term care. Peter Alders, PhD, MSc Ministry of Health, Welfare and Sport, The Hague, the Netherlands
ACKNOWLEDGMENTS I am grateful to Richard Frank for discussing the paper and Katie Dean for research support. The Commonwealth Fund provided support for this research. The views presented here are those of the author and should not be
MARCH 2015–VOL. 63, NO. 3
JAGS
attributed to The Commonwealth Fund or its directors, officers, or staff. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: The author was the sole contributor to this letter. Sponsor’s Role: Part of the research was done during a Harkness Fellowship at Harvard Medical School. The Commonwealth Fund funds the Harkness Fellowship.
REFERENCES 1. Alecxih L, Shen S, Chan I et al. Individuals Living in the Community with Chronic Conditions and Functional Limitations: A Closer Look. Washington, DC: Office of the Assistant Secretary for Planning & Evaluation, US Department of Health and Human Services, 2010. 2. Wagner EH, Austin BT, Davis C et al. Improving chronic illness care: Translating evidence into action. Health Aff 2001;20:64–78. 3. Marek KD, Popejoy L, Petroski G et al. Nurse care coordination in community-based long-term care. J Nurs Scholarsh 2006;38:80–86. 4. Walsh EG, Freiman M, Haber S et al. Cost Drivers for Dually Eligible Beneficiaries: Potentially Avoidable Hospitalizations from Nursing Facility, Skilled Nursing Facility, and Home and Community Based Services Waiver Programs. Waltham, MA: RTI International, 2010. 5. Naylor MD, Brooten DA, Campbell RL et al. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. J Am Geriatr Soc 2004;52:675–684. 6. Brown RS, Peikes D, Peterson G et al. Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff 2012;31:1156–1166. 7. Brown R, Mann D. Best bets for reducing Medicare costs for dual eligible beneficiaries: Assessing the evidence. No. 7574. Mathematica Policy Research, 2012. 8. Wolff JL, Boult C. Moving beyond round pegs and square holes: Restructuring Medicare to improve chronic care. Ann Intern Med 2005;143: 439–445. 9. DeJonge KE, Jamshed N, Gilden D et al. Effects of home-based primary care on Medicare costs in high-risk elders. J Am Geriatr Soc 2014;62:1825–1831. 10. De Veer AJ, Brandt HE, Schellevis FG et al. Buurtzorg: nieuw en toch vertrouwd. Een onderzoek naar de ervaringen van cliënten, mantelzorgers, medewerkers en huisartsen. [Care in the neighborhood. A study about experiences of clients, care staff and general practitioners involved]. Utrecht: Nivel, 2008.
THE PLAY OF CHANCE MAY, IN SOME CONTEXTS, BE CONSISTENT To the Editor: As long as there are elderly adults with nonvalvular atrial fibrillation (NVAF),1 there will be elderly adults with NVAF who have stroke attributable not to cardiogenic embolism but to coexisting stenotic cerebrovascular disease,2 simply because NVAF1 and nonembolic cerebral infarction (the latter a surrogate for stenotic cerebrovascular disease) are both age related.1,3 In one study, there was a positive correlation (correlation coefficient = 0.187, P < .001) between CHADS2 score (which was originally compiled to evaluate the risk of stroke attributable to cardiogenic embolism in NVAF) and number of arteries with concomitant atherosclerosis (severity ≥50%) in 780 consecutive individuals with NVAF of mean age 69.5 who had undergone angiographic studies at index stroke.2 Likewise, as long as there are women aged 60 and older with autoimmune hypothyroidism,4 there will be women
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
