The cost of health care in the US is higher than anywhere else in the world, and yet we are not healthier than our peer nations. In fact, in terms of such measures as infant mortality and life span, we don't measure up. Why is this? Many people involved in providing or receiving care have some pretty good ideas about what costs so much, and what we can do to reduce costs and improve quality. Sharing these stories is an important step in creating affordable universal health care.
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What's up with people who are in the hospital a very long time?
I just finished reading a very delightful "A Piece of My Mind" essay in JAMA (The Journal of the American Medical Association.) The JAMA is primarily a research journal, filled with new scientific or semi-scientific studies and comments on those, plus reviews of the literature and editorials on science or politics. There are also letters and announcements and educational sections for doctors or patients, even poems, but the part I like to read all the way through is called "A Piece of My Mind." These essays are almost always stories about something that has made a profound impression on the writer. The most recent title was "A Place to Stay," written by Benjamin Clark, an internist at the Yale New Haven Medical Center. He describes a patient who is stuck in the hospital probably for the rest of his life due to a medical condition whose treatment requires management that can't be done anywhere else. It's lovely, and true (even if the details are not, and I'm guessing they aren't) and I won't describe it more fully because it is available in full at the link.
It made me think about the vast diversity of patients I've known who have stayed in the hospital for way too long.
The “Piece of My Mind” story was about a well-educated and
deeply lovable person with a bad disease that was in no way his fault. Most of
the patients we end up taking care of for very long stretches are not this way.
This sometimes makes them less appealing. Still, all of them are people with
whom we become intimately familiar, knowing their families and their prospects
as well as their everyday quirks, preferences and routines. We fuss and connive
about how we might move them out of our hospitals and eventually, for most of
them, this happens. They don’t usually die with us.
During their stays we feel
frustration and experience dread as we repeatedly fail to do our job as
hospitalists which is to get them better and get them out. As the days pass we adjust
medication and perform diagnostic tests, consider and try new approaches and
eventually manage expectations.
We feel that these cases are failures because we can’t get
the patient well as fast as we think we should. This is partly because of the ways hospitals are paid to take care of
people. For decades we have been urged to reduce the number of days patients
stay in the hospital. This started decades ago when healthcare costs were first
starting to be alarming to payers, especially Medicare. Patients who remained
in the hospital for many days often were getting complications, pneumonia,
other hospital acquired infections, confusion, and these extra days were
costing insurance companies and the government lots of money. Payment models
were changed and we were paid flat amounts for a given diagnosis. Because of this, our hospital made more money if a patient was cured more quickly than
expected. This can be good all around. Patients don’t usually want to be in
hospitals and often get sicker if they stay, and hospitals don’t want to foot
bills that are made larger by more days and more tests and treatments. This
method of payment gave us financial incentives to cure patients rapidly. They
also left us no room in our hearts or minds for the outliers who take a long
time to be ready to leave.
Beside the patient in the “A Piece of My Mind” story, who
are these patients?
We just discharged a patient who had been in our hospital
for over a month. She had been heavy all of her life, but after having children
her situation became dire. She had a gastric bypass and lost 100 pounds, which
brought her down to a manageable 300 pounds. Job changes resulted in gaining
most of that weight back, and then a divorce made her even less active as she
turned to alcohol for comfort. She finally sought help when she was 600 pounds,
couldn’t get out of bed and was so swollen that half of her skin was oozing,
some of it covered with infected wounds. When she got to our emergency
department it was difficult to maintain her oxygen level. She could barely
breathe and was so heavy and weak that she could only just move her arms. Her
chronically low oxygen levels had led to severe pulmonary hypertension and so
much of her weight was retained fluid. We began the process of giving her
diuretics to remove extra fluid, cleaning and dressing her wounds, using
mechanical lifts to be able to lift the skirt of fat and fluid to care for the
skin underneath. She was horribly malnourished, since her diet was terrible and
her gastric bypass made her unable to absorb nutrients well. She was depressed
with horrible self esteem, and was surprised to learn that we thought this was
a problem. Over the course of 5 weeks she was able to lose nearly 200 pounds of
primarily water weight, with daily attention to replacement of rapidly depleted electrolytes. Physical therapy worked with her daily and by the time of
discharge she could climb stairs and walk the halls alone. She will get further
rehabilitation which should allow her to cook and bathe and even drive
independently. During the 5 weeks we all got to know her well and discussing
her success became a high point of all of our day. There was no point during
those 5 weeks that she could have successfully left the hospital.
Another patient arrived with high fevers and back pain. He
had been in recovery from heroin abuse but had relapsed. He had Staph aureus
growing on one of his heart valves and had been throwing little infected blobs
to his spine, his spleen and his kidneys. He was treated with the proper
antibiotics, but ended up with abscesses in his brain, which made him confused
and difficult to handle. He had a long term central intravenous catheter (PICC
line) that we placed in hopes that he might be able to get antibiotics as an outpatient,
but his parade of misfortunes made it impossible for him to survive outside of
an actual hospital and the temptation to inject heroin into his pristine PICC
if he were on the outside made it unwise once he stabilized. Nursing homes do
not like young drug addicts because they assume that they won’t play well with
their primarily ancient clientele. He needed at least 6 weeks of intravenous
antibiotics. He was ours. No other options. After he stopped being a complete
pain in the rear he was like a family member.
Who pays for all of these hospital days? It varies. In
actual fact, we all do. Hospitals eat some of the costs and pass them on to
other payers if they are to remain solvent. All of us who work, pay taxes, buy
insurance or use medical services pay in some way.
So what do we do about patients like this, ones who can’t go
home? We struggle. We stew. We blame ourselves and them. Discharge planners shake their
heads and make more telephone calls. We dread our daily visits in which there
is nothing much to say that we haven’t all said before. At our best we finally
come to peace with the fact that these patients and their epic hospitalizations
are part of what is real about our job and not just inconvenient outliers.
I have been doing lots of bedside ultrasound lately and realized how useful it would be in areas far off the beaten track like Haiti, for instance. With a bedside ultrasound (mine fits in my pocket) I could diagnose heart disease, kidney and gallbladder problems, various cancers as well as lung and intestinal diseases. Then I realized that I would have to take a whole bunch of ultrasound gel with me which would mean that I would have to check luggage, which is a real pain when traveling light to a place where luggage disappears. I heard that you can use water, or spit, in a pinch, or even lotion, though oil based coupling media apparently break down the surface of the transducer. Or, of course, you can just use ultrasound gel. Ultrasound requires an aqueous interface between the transducer and the skin or else all you see is black. Ultrasound gel is a clear goo, looks like hair gel or aloe vera, and is made by several companies out of various combinations of propylene glycol, glyce
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