MD, FRCPC, FRCP, Professor of Medicine
(Geriatric Medicine & Neurology)
Kenneth Rockwood has had a longstanding interest in clinical and epidemiological aspects of frailty, dementia and delirium. He has focused his investigations on the complexity of frailty, and on what can be termed ‘clinico-mathematical correlation’. Prof. Rockwood has published more than 300 peer-reviewed scientific publications and seven books, including the seventh edition of the Brocklehurst’s Textbook of Geriatric Medicine & Gerontology. He is the Kathryn Allen Weldon Professor of Alzheimer research at Dalhousie University, and a staff internist and geriatrician at the Capital District Health Authority in Halifax. He holds several CIHR grants, including as Principal Investigator of the Canada China Collaboration on Aging and Longevity and the Canadian Dementia Knowledge Translation Network. The latter is a national, multicentre project to provide better care for people with dementia by facilitating and carrying out translational research and knowledge translation. A native of Newfoundland, he became a Doctor of Medicine at Memorial University in 1985,completed internal medicine training at the University of Alberta and geriatric medicine at Dalhousie University, where he has been on staff since 1991.
Discussion with Dr. Rockwood
What changes have occurred over the past 25 years that have significantly affected how health services are designed and delivered to Canadians today?
To me, three changes in the last 25 years have significantly affected how health care services are delivered. We treat more people as outpatients, not inpatients, so that inpatients tend to be more ill. Our system is much less sexist than it was 25 years ago, with (not coincidentally) better recognition of the family lives of health care providers, especially trainees. From an inpatient’s point of view, the latter may well be a double-edged sword, because one result is less continuity in the people who provide care. Overall, however, having more well-balanced health care providers will be better.
A very recent, hopeful trend is integrating what were considered traditionally “medical” and “social” services. This is coupled with the move to so-called “co-leadership”, which facilitates more meaningful decision-making by people at the pointy end of care, working with professional health administrators. I see both as aspects of what we must do, which is to reduce the barriers between what the system provides and what people need.
What are the most important challenges facing the Canadian Health system in the next decade?
Most importantly, we must get to grips with the complex care needs of the people who are often our most ill patients, who in any case are contemporary health care’s single largest constituency. These are frail older adults, who by definition have multiple, interacting medical and social problems. The complexity of their needs is a special challenge to a health care system. That is because our system idealizes patients who only have one thing wrong at a time. Think about it. We organize hospitals by wards devoted to not just organ systems, but the procedures associated with them. So cardiac surgery has its ward, distinct from cardiology. Within cardiology, people with a heart attack have different care needs from those with heart failure. Science proceeds by knowing in ever greater detail; in medicine, the result is sub-sub-specialization. That is great for people with only one health condition – it is clear that, in those circumstances, being cared for by teams with highly specialized skills gives better results. But their skills are often irrelevant to patients who have not just “their” problem, but many others as well. Providers tend to see this as a problem with the patient, rather than their having redundant skills. In consequence, patients can be denigrated as “bed blockers” or “gomers” or as having “families who refuse to care”.
Look too at how we have hospitals account for themselves. We reward them for the greatest efficiencies for single problems, termed “the most responsible diagnosis”. We pay lip service to complexity of care, and distort performance by rewarding the “one thing most wrong”. Perverse incentives allow us to discharge home patients who cannot walk, or who have active delirium, because there is no diagnostic code for “cannot walk” and no disincentive for missing a delirium diagnosis. Likewise, the accepted average length of stay for hip fracture rehabilitation is too long for patients who do not have to climb stairs, and too short for those who need to get up one flight. But our official statistics don’t code “care requirements”; often we barely consider them in practice, so patients and families must fend for themselves if they don’t speak up. That erodes trust. Perverse incentives give perverse results, everywhere. Health care is no different.
Similarly, consider how we teach students. Again, for the sake of making things comprehensible, we teach one problem at a time, because that is an efficient way to learn. But a side effect of this is that we delegitimize most people who need care, including many of the patients who need the most care Students expect to care for 37 year old patients with 1.1 problems, because that is the typical age and degree of complexity in the cases by which they are taught. They see an older adult with multiple, interacting medical and social problems, and they believe that looking after them – relieving their pain and suffering, improving their function, keeping them from dying prematurely – is not “real” medicine. Sadly, the system reinforces this in many ways, not the least in rewarding single procedures very highly, and largely not paying any premium for patients with complex needs. Perverse incentives – we do not reward the care of our most complicated, challenging patients. Guess what we get?
Another side effect of ignoring complexity is excessive cost. Routinely, expensive drugs are prescribed as though they were the first, or second, or fourth or fifth drug a patient is taking. For this, there might be a valid evidence base. But there is no valid evidence base for employing a new drug as the tenth or fifteenth drug in a patient’s regimen. Even so, I see new drugs for lowering cholesterol or lowering blood pressure used in very elderly, very medicated, very frail patients, for whom there is not a shred of evidence that the new drugs will help. In fact, because the chance of an adverse drug interaction increases exponentially with the number of drugs that are prescribed, the chance that the new drug will do harm is commonly much higher than the chance that it will do good. But the incentives are towards starting, not stopping, doing things to patients, not doing things for them, bending to families who want “everything done”, not helping them understand how the needs of the person they care for are likely to be adversely affected by their demands. We have big incentives to add people to wait lists, about which we then fume, and no incentive to see whether a given procedure will help them in the context of what else they might have wrong. That is largely because we conceive of, facilitate and reward health care on the one-thing-wrong-at-a-time approach. Perverse incentives: we are paying for what we do not want, but because we pay for it, that is what we get.
What initiatives need to be considered to effectively meet these challenges?
We need better recognition by all partners that if we are to make Medicare viable, we must address the problem of complex care needs. Instead, what is most often being put on the table, in various guises, is the private pay option. That is disastrous from Medicare’s standpoint, because it will skim the uncomplicated patient, dump them back in the public system when they get complicated, and do nothing to address the perverse incentives which now exist. (We see this even now in many “assisted living seniors facilities”, which send patients to the Emergency Department as soon as their money runs out, having collected huge risk premiums for years when the person did not need much.) Unless we get management of complexity on the table as the preferred option, and seriously innovate with this in mind, the financial incentives now in place – paying for what is often not just superfluous, but harmful, and not paying for what we need - will ensure that taxpayers pay to erode Medicare. There are dozens of pragmatic steps that could now be taken, but they will not work if they are not rewarded. True leadership is needed to save publicly funded Medicare.