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The American
health care delivery system is reaching a point of
crisis. Its costs are escalating as
outcomes and quality of care are diminishing.
It focuses on crisis management and treating problems aggressively with
medicines and interventions of uncertain benefit, while neglecting true health
and wellness. It is estimated that 1
trillion dollars annually is being spent on unnecessary
care, much of which occurs in the hospital, and some of which leads to harm.
Medicare, although concerned about rising health care costs, does little to
address the real issues and actually but subtly encourages
aggressive management when less could indeed be more. Hospital acquired infections and death from
medical errors are far too numerous, often occurring in patients who did not
have to be hospitalized in the first place.
Patients and physicians are frustrated, while private insurers and both
Medicare and Medicaid are becoming unable to fund this excessively costly care
without raising premiums or exhausting trust funds. Something certainly must be done.
We wish to focus on one
glaring problem occurring in hospitals that is relatively easy to fix and whose
resolution could improve outcomes.
Currently, as many hospitals close their doors to primary care
physicians (PCPs) and instead rely on hospitalists, there often is a lack of
communication between these doctors that can lead directly to costly
mistreatment. A true and common story
will set the stage.
Mrs. P suffers from
dementia and lives in a nursing home. One day she became unresponsive. The nurse on duty could find no obvious
reason and so immediately called 911 and sent her to the hospital. While she quickly woke up, the emergency
medicine physician admitted her for further evaluation. Her assigned hospitalist found bacteria in
the urine and treated her for a urinary tract infection, calling in an
infectious disease consultation and starting her on a potent intravenous
antibiotic. He also requested
consultations from a cardiologist and a neurologist to determine the cause of
her unresponsiveness, and they ordered further tests including an MRI and an echocardiogram. Mrs. P became more confused, was exposed to
aggressive evaluation and treatment, and was losing her strength as a result of
bed confinement. She was ultimately sent
back to her facility after tens of thousands of dollars of medical care, worse
off than when she arrived. She was fortunate
to have not suffered further harm from her hospital-induced delirium and the
potent medicines she received.
Let’s dissect what
happened, and why.
The emergency medicine
physician was faced with a lethargic person who could not give a coherent
history, hence she was subjected to an extensive work-up and then admitted to
the hospital. The hospitalist, likewise, was faced with a patient he had never
met before, with only the emergency room records as guidance. He detected
neurologic, infectious, and cardiac problems and so called for specialist
consultations and extensive testing.
It is unfortunate that
the nursing home nurse did not call the patient’s primary care physician (PCP)
upon transfer, but it was even more unfortunate that her PCP was not contacted
at any time during her emergency room stay or subsequent hospitalization by any
of the doctors who saw her. Had they
called Mrs. P’s PCP they would have learned that she had a long history of
progressive dementia and similar unresponsive episodes in the past that had
been fully evaluated. Further, they would have learned that she always carried bacteria
in her urine without tissue invasion and that she could have received any of
her treatments in the nursing home where she would have been safer and more
comfortable, at a far lower cost. A recent
study showed that 20% of hospitalized patients who
receive antibiotics develop an adverse event so avoiding unnecessary
antibiotics must be a top priority.
The growth of the hospitalist movement over the past twenty years has been truly
phenomenal – at 50,000 physicians it is the largest medical sub specialty,
surpassed as a specialty only by general internal medicine at 109,000 and
family medicine at 107,000. Studies suggested that quality was
improved and costs reduced with hospitalist care. This was especially true for
complicated patients who required multiple physician visits and interactions
each day, something increasingly difficult for the community based PCP to
achieve.
The hospitalist is
experienced in managing the types of medical issues that lead to
hospitalization and works full time in the hospital. As a result they come to
know how to “get things done” and potentially can give more efficient care. But
they are far too often burdened with large numbers of patients, and often know
very little about the patients they are treating. With too many patients to
care for and too little information they tend to request consultations for
problems that, given adequate time, they could have managed. This is especially
problematic if the patient has multiple medical issues and is elderly. Other
reasonable concerns are the diminishment of the
patient-physician relationship and miscommunication and discoordination at both
admission and discharge. Communication
with the patient’s PCP however could alleviate many of these issues.
PCPs have been –
generally – content to allow the hospitalist to manage their patients, indeed
it has been a major advantage for many. PCPs have seen their overhead costs rise
dramatically, necessitating seeing
more and more patients per day for less and less time
each in order to cover those overhead costs. The multitude of rules,
regulations and requirements foisted upon them by the insurers has further
consumed extensive time, time that previously could be used to care for their
hospitalized patients. Today, many PCPs do not have time to see patients in the
hospital, while others are barred
from doing so by hospital rules.
In this situation, both
PCPs and hospitalists could have improved Mrs. P’s care substantially, and
reduced the cost of unnecessary care, simply by communicating. A call or text by the hospitalist to the PCP
upon admission and at various decision points might have enabled Mrs. P to
leave the hospital before any consults were called, before extraneous tests
were ordered, before antibiotics were initiated, and before she became more
confused and weaker. More than half of
elderly patients leave the hospital worse
off
than when they came in, and involvement of a PCP in a patient’s care could
potentially facilitate more rapid discharge and less aggressive treatment.
A recent survey
indicated that 95% of hospital leaders are concerned that discharge
communication is “inefficient” and 80% have concerns about communication among
care team members. PCPs complain that
they are never called. Hospitalists often state that they just don’t have time
to call the PCP but when they do, the PCP is not available. Each is culpable.
Each must remember that the issue at hand is the patient’s care and welfare,
not their convenience or preferences. It is a matter of professional
responsibility. What could help? The electronic medical record was supposed to
solve these sorts of problems but it has not and probably will not in the foreseeable
future. There are some HIPPA compliant texting systems which could be utilized
and there are HIPPA compliant smart phone apps that can coordinate among all
involved physicians, nurses, hospitals, other facilities and even the patient
him or herself. One of these types of systems could potentially negate the
issue of non-availability although it will not top the value of nuanced
conversation among physicians.
In the end, there is
nothing that trumps good physician to physician communication. It must be
incumbent on hospitalists to involve PCPs during in-patient stays and it must
be incumbent on PCPs to respond to hospitalists and provide crucial insight and
information when asked to do so. Not
only can outcomes be improved, but costs can drop and patients and their
families can feel more comfortable knowing that their own doctor is involved in
their care. If necessary, hospitals should
set policy that makes hospitalist to PCP communication mandatory; everyone will
benefit. Very basic solutions can frequently
lead to profound improvement.
This post was co-authored by
Andy
Lazris, MD, CMD a primary care physician whose private practice focuses on
geriatric patients especially those residing in long term care and assisted
living facilities. He is the author of Curing Medicare and co-author of Interpreting Health Risks and
Benefits
and was first published on Medical Economics on July 29, 2017
