Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

https://caltcm.memberclicks.net/assets/documents/acc_aha_chf_2013_guidelines.pdf

2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Objective: The objective was to provide guidelines to clinicians for the evaluation, treatment, and prevention of vitamin D deficiency with an emphasis on the care of patients who are at risk for deficiency. Participants: The Task Force was composed of a Chair, six additional experts, and a methodologist. The Task Force received no corporate funding or remuneration. Consensus Process: Consensus was guided by systematic reviews of evidence and discussions during several conference calls and e-mail communications. The draft prepared by the Task Force was reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and cosponsoring associations, and it was posted on The Endocrine Society web site for member review. At each stage of review, the Task Force received written comments and incorporated needed changes. Conclusions: Considering that vitamin D deficiency is very common in all age groups and that few foods contain vitamin D, the Task Force recomme...

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Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline

OBJECTIVE\nThe objective was to provide guidelines to clinicians for the evaluation, treatment, and prevention of vitamin D deficiency with an emphasis on the care of patients who are at risk for deficiency.\n\n\nPARTICIPANTS\nThe Task Force was composed of a Chair, six additional experts, and a methodologist. The Task Force received no corporate funding or remuneration.\n\n\nCONSENSUS PROCESS\nConsensus was guided by systematic reviews of evidence and discussions during several conference calls and e-mail communications. The draft prepared by the Task Force was reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and cosponsoring associations, and it was posted on The Endocrine Society web site for member review. At each stage of review, the Task Force received written comments and incorporated needed changes.\n\n\nCONCLUSIONS\nConsidering that vitamin D deficiency is very common in all age groups and that few foods contain vitamin D, the Task Force recommended supplementation at suggested daily intake and tolerable upper limit levels, depending on age and clinical circumstances. The Task Force also suggested the measurement of serum 25-hydroxyvitamin D level by a reliable assay as the initial diagnostic test in patients at risk for deficiency. Treatment with either vitamin D(2) or vitamin D(3) was recommended for deficient patients. At the present time, there is not sufficient evidence to recommend screening individuals who are not at risk for deficiency or to prescribe vitamin D to attain the noncalcemic benefit for cardiovascular protection.

Evaluation, treatment, and prevention of vitamin D deficiency: An endocrine society clinical practice guideline (Journal of Clinical Endocrinology and Metabolism (2011) 96, (1911-1930))

CA : A Cancer Journal for Clinicians

Establishing a palliative care service can improve patient care and ease family concerns for patients who are hopelessly ill. For the hospital, such services can improve utilization outcomes. Take a closer look at a palliative care service operating for nearly five years at Mount Sinai Hospital in New York City.

Palliative care programs: what, why, and how?

Palliative care is specialized medical care for people with serious illnesses. It is focused on giving patients relief from the symptoms, pain, stress, and treatments of a serious illness—whatever the diagnosis. The goal is to provide the best possible quality of life for the patient and the family.1 Although 66% of large hospitals have a palliative care program,2 there is significant variation in the types of programs and services offered, giving rise to concern regarding variation in the quality of care provided by these programs.

The article by Walling and colleagues3 in this issue of JAMA Internal Medicine has important implications for the field of palliative medicine that reach beyond the specific findings of the study. Veterans Affairs (VA) has exemplified the type of quality improvement initiatives that need to occur across a broad range of health care settings and populations to expand access to supportive cancer care. The study also found that despite system-wide efforts to improve access and quality, a significant amount of work remains to elevate the quality of supportive cancer care provided in the VA, which underscores the need for quality initiatives to be iterative and ongoing.

One of the most significant findings of the study is that 86.4% of the veterans who died an expected death during the study period were referred to either palliative or hospice care, reflecting their deep penetration within the VA system. Although the study evaluated only a cohort of veterans with common solid tumors (as opposed to other noncancer diagnoses), the cohort had varying prognostic and clinical features. The Veterans’ Health Care Eligibility Reform Act of 1996 (Title 38 Code of Federal Regulations §17.38) standardized the provision of hospice and palliative care to eligible veterans who need these services. It established that hospice and palliative care are covered services, having equal priority with any other medical care service provided by the VA. This standardization of access systemwide created a culture in the VA where palliative and hospice care are integrated into the continuum of cancer care. The results of this study support the use of new standards for access to quality hospice and palliative care as a potential policy lever for the Centers for Medicare & Medicaid Services and accreditation bodies to scale palliative care delivery across health care settings outside the VA.

A second important implication of this study for the field of palliative medicine is that it serves as a proof of concept that quality of care can be measured in an older and medically complex patient population. This is a pivotal finding, since discussions regarding improving the quality of palliative care are premised on the notion that we can systematically measure quality. This study demonstrates that such measurement is possible and should be replicated across systems and settings. The study used the Cancer Quality–Assessing Symptoms and Side Effects of Supportive Treatment (ASSIST) measures, which span multiple domains of care from symptom management to spiritual support. The VA has demonstrated that quality can be measured in the veteran population using this tool. The study also highlights, however, that the assessment of meaningful and person-centric measures is costly. Specifically, data abstraction for the Cancer Quality–ASSIST measures required 3 days of training for experienced oncologic nurses, access to a real-time consultation with a senior nurse reviewer, and the use of the VA’s information technology infrastructure, which is more comprehensive than that of most other integrated systems or health care providers. On average, complete medical record abstraction required more than 2 hours for each patient. As such, a significant barrier to other health care systems or providers in carrying out similar quality improvement initiatives is the potentially high cost of the measurement process.

The study by Walling et al3 also demonstrates the significant gap between the evidence base for supportive care processes that improve quality of life for patients with cancer and the variable implementation of such care processes in standard oncologic practice. This implementation “gap” represents a significant challenge for the field of palliative medicine and is the focus of 2 recent articles4,5 regarding the need for investigators to write about their implementation experiences within a scientific framework and with a common language to maximize learning from current and past initiatives. Although we know what works for improving care in a population of older veterans, we need more information regarding how and why some processes of care are more consistently and successfully implemented than others. Why was the VA more successful in improving quality indicators in the inpatient setting? A greater focus on implementation research would enable innovative approaches to overcoming barriers in adopting evidence-based interventions to be more widely understood and disseminated.

Last, the study by Walling et al3 highlights the unique aspects of the VA system that both facilitate the assessment of quality and may have led to the relatively high quality scores in some domains. Despite the fact that, on average, veterans received only about half of recommended care, significant variation occurred across measures and settings, and there is reason to believe that the VA may be on the higher end of success in terms of these outcomes compared with other settings.6–8 As an integrated health care system functioning under a global budget with a fully employed clinical staff, the incentives promoting supportive care services are likely stronger than in nonintegrated systems in which the quality improvements and efficiencies generated from greater supportive care services may not be enjoyed or even recognized by the provider of such services. The extent to which those system design factors and incentives influenced the care provided in the VA is unclear but worthy of further study. Similarly, the extent to which the VA links clinician incentives, training, and electronic medical record processes to make quality measurement and assessment more visible and actionable at the point of care is unknown. Does the electronic medical record prompt clinicians to assess shortness of breath? Does the VA reward or penalize movement on the Cancer Quality–ASSIST measures? What were the specific actionable steps taken by the VA to address the results of this study? More information about these issues would facilitate widespread adoption of these care processes and support efforts for ongoing improvement in the quality of palliative care in the VA and nationally.

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It is possible: quality measurement during serious illness.

The disciplines of bioethics and geriatrics have had parallel development in recent years. From small and relatively esoteric fields 15 or 20 years ago, both have grown enormously. Although the numbers of geriatricians and ethicists in practice or in academic centers have increased substantially, these disciplines represent areas in which better understanding is sorely needed. This bibliography is intended to assist the clinician in locating salient literature concerning bioethical issues in geriatric medicine and research. It is highly selective; it does not attempt to cover all the literature on bioethics. There are several excellent general bioethics bibliographies for clinicians in the recent literature, as well (not limited to clinical journals or clinical topics), some of which are included in section 13 for the reader's further information. The ethical issues that arise in geriatric medicine are similar to those that arise in the care of younger patients, but certain kinds of problems happen with far greater frequency. Dilemmas concerning decisions about care at the end of life are particularly relevant in geriatrics, as persons of extreme old age are often presented with choices about life-sustaining therapy when critical illness occurs. This includes decisions about cardiopulmonary resuscitation and nutritional support. When these clinical decisions arise in the care of patients who cannot decide for themselves, the question arises as to what role the assessment of "quality of life" ought to play in decisions to pursue or to forego life-sustaining therapy. Informed consent to treatment and to participation in research has been an important area of ethical investigation. Dilemmas about consent to treatment are complicated in some elderly populations because of the higher incidence of cognitive impairment and the higher incidence of the clinician's suspicion (or assumption) of cognitive impairment. In consent to research, there are additional issues of voluntariness and equitable selection, especially when subjects are residents of nursing homes. Because of the increasing numbers of elderly persons in our society, and because of the role of social resources (federal, state, and local) in acute and long-term medical major concern in gerontologic bioethics. The topic headings for this bibliography reflect these common issues which arise in the care of the elderly.+2

Selected bibliography of recent articles in ethics and geriatrics.

Using data to sustain and grow hospital palliative care programs.

Palliative care has become America's fastest growing medical specialty. ere are now more than 6,500 physicians and 13,500 nurses certified in palliative care, and palliative care teams available in more than 80% of American hospitals with more than 50 beds.

Diane E. Meier

Papers

Palliative care programs: what, why, and how?

It is possible: quality measurement during serious illness.

Selected bibliography of recent articles in ethics and geriatrics.

Using data to sustain and grow hospital palliative care programs.

Palliative Care Improves Quality of Care, Lowers Costs.