Comments on: Unnecessary hospital admissions cost money and can harm patients

By: Doc Stone

Doc Stone — Tue, 20 Oct 2009 23:47:07 +0000

Dr. Turkewitz:

No, it isn’t me seeing the patient in the ER. The last time I was in an ER it was as a patient. I hate the places and never go anymore. Once upon a time I would go–for the specific reason of keeping my patients from being admitted unnecessarily. It was the only way. I never figured out how to get paid adequately for it and it wore me out so I stopped. But when I did, it worked nicely in getting the hospital beds occupied by the people who needed them. Sometimes I KNEW they didn’t need admission but there is no way that it wasn’t going to happen unless I showed my face and took responsibility for it.

My question is an honest one. What if anything can we do to make it a viable practice and normal again for you and for me or someone else who knows the patients to be seeing them in the ER in at least some circumstances.

By: Matt

Matt — Tue, 20 Oct 2009 15:52:37 +0000

“My original point was that the threat of lawsuits causes the ER physician to over-estimate the risks of returning a chronically ill patient to his or her home, and to under-estimate the risks of a hospital admission.”

So how do we reduce that risk or educate ER physicians about how to spot and better avoid that risk?

By: Stuart Turkewitz, MD

Stuart Turkewitz, MD — Tue, 20 Oct 2009 03:31:48 +0000

To Doc Stone:
The usual scenario (in our practice) of a patient being sent to the ER is the need (usually a telephone judgment) for an urgent test, such as a hip X-Ray for example, that cannot be done in our office. This is extremely common, and always accompanied (in our practice) by a phone call to the ER explaining specifically what the patient is being sent for.
The reality is that once in the ER, the ER MD (I assume that’s you) is confronted with a patient with multiple chronic illnesses, and who “doesn’t look so good” even at baseline. My original point was that the threat of lawsuits causes the ER physician to over-estimate the risks of returning a chronically ill patient to his or her home, and to under-estimate the risks of a hospital admission. As for the primary care doc, we are ill-equipped to argue with the physician who has actually seen the patient, despite our frequent suspicion tht the patiet being described is not truly different than his baseline.

By: Doc Stone

Doc Stone — Sun, 18 Oct 2009 04:17:59 +0000

Ditto what family practitioner said . . . but one question.

It seems that we are assuming that the disposition of the patient once they get to the ER is out of the hand of the patient’s primary care doctor. I know that most of the time it is true but is the assumption necessary?
Once we find the patient with a primary care doctor, one who is contacted by the patient or family and who could see the patient urgently in his office if medically appropriate but who finds it necessary to direct the patient to the ER, is it possible to imagine a scenario in which we have recreated a sustainable (and tolerable for primary care physicians) practice model in which the primary care physician or a partner with some knowledge of and relationship with the family and patient is the one making the disposition?

By: Stuart Turkewitz, MD

Stuart Turkewitz, MD — Sat, 17 Oct 2009 20:10:49 +0000

I am the geriatrician whose blog entry (on my brother’s site) triggered the above comments. To Family Practitioner: sending an elderly patient to an ER ought not to trigger an automatic admission. When the patient requires a CT scan after a fall, or needs to have a PE ruled out urgently, or a hip XR urgently, the ER is appropriate. My point was that the ER MD looks at an elderly chronically ill patient, and fears only the consequences of sending her home, not the substantial health and economic consequences of admission.
To Anonymous Q: I’m also very sorry about your Mom. If she needed a CT of the brain to rule out a bleed, or even a repeat CT a few days later, then that’s what she should have had. Spending time in the hospital for things that can be had as an outpatient is not “providing optimal care”, A hospital admission carries many risks and is not “erring on the side of caution”.
To Erik: I certainly agree that overworked and understaffed nursing homes are often anxious to transfer patients with any change in status, or occasionally just difficult patients. Unrealistic families put even more pressure on the nursing home staff, and I have no good solution for this. My point was that, whether coming from home or from a nursing facility, there are many times when an acute reversible problem needs to be ruled out. When the pneumonia, electrolyte disturbance, anemia, hip fracture, intracranial bleed or whatever has been ruled out, ER physicians are STILL prone to recommend hospitalization simply because they fear the consequences of discharge more than they fear the consequences of hospital admission. It is this asymmetry in the ER docs’ calculation that is directly attributable to the fear of malpractice lawsuits.
To Erik again: I also agree that more well-trained geriatricians who speak to families would help enormously. The obvious solution: higher pay for geriatricians and better reimbursements for talking to families!!!!!

By: Doug

Doug — Fri, 16 Oct 2009 19:29:17 +0000

Erik is right. Every ER doc has had the experience of explaining to the family that everything looks OK for now. The family refuses to take their family member home, and we are forced to convince an overworked hospitalist to admit the patient. Believe me, if the hospital demanded a $100 copay for the admission, we could cut these in half tomorrow.

By: Erik

Erik — Fri, 16 Oct 2009 17:41:15 +0000

It is rarely the MD driving the admission – it’s almost always the nursing home where the pt lives. Compound this with family member who have very unrealistic expectations and are mistaken about the pt’s baseline (she was just fine until this morning…) and of course they pt will be admitted.

Mutliple imagings studies, diagnsotic procedures, lab tests and drug infusions will occur with minimal if any change in the pt’s condition; the family will refuse hospice and we start the process all over again.

If we had more geriatricians, and they were able to spend enough time with families, they could explain that the pts will never get any better, that there will be good and bad days, and that hospital admissions are a good idea some (but not all) of the time. But apparantly we call that a death panel…

Heaven forbid we use the hospital for patients (of any age!) with reversible conditions…

By: AnonymousS

AnonymousS — Fri, 16 Oct 2009 17:19:41 +0000

anon Q

I’m sorry about what happened to your mother, but these are the costs and benefits that we have to weigh in medicine. On one end you can just admit everybody with HUGE monetary costs to the system and on the other end you can admit no one with HUGE costs to the public. We are of course in the middle of that scale somewhere.

Although doctors and politicians can come up with some neat tricks to reduce costs without reducing quality we will always be at a point where we have to balance the two.

Doctors are a big driver of cost in medicine and it would be irresponsible not to be concerned with monetary costs. This is not about a a situation of right and wrong because you are balancing the risk of injury to the patient (many times less than 1%) and the cost to the system ($5-10k in hospital bills).

As the government takeover is imminent, we are going to have to tinker with this sliding scale. Woe to that person who has to make these decisions because no matter what they do they’re going to either take criticism from either the patient or the public.

By: Just one anecdote

Just one anecdote — Fri, 16 Oct 2009 17:14:41 +0000

I have personally cared for a patient who died solely because she was asked to go to the ER inappropriately.

She was a 40-something year old woman who had had type I diabetes since her teens and been on hemodialysis since her 20′s. A common long term complication of renal failure is metastatic calcification, or the deposition of calcium and phosphate in places such as the arteries of the fingers and toes. This can look like gangrene to the untrained eye, and in fact, this is exactly what happened. A podiatrist took one look at this poor woman and sent her to the ER. She followed his instructions without questioning them. She waited in the ER a few hours before being told there was nothing they could do for her, since she did not truly have an infection. As she was getting off the guerney to leave, she fell and broke her hip. (Renal failure also causes abnormal resorption of bone similar to osteoporosis.) To make a long story short, she did not survive the complications of hip replacement surgery.

Of course, there was no way to predict that this long chain of events could have occurred simply because someone was sent to the ER, but I still think of it every time I am forced to do so because a patient has something I cannot handle in the office.

By: AnonymousQ

AnonymousQ — Fri, 16 Oct 2009 14:48:55 +0000

I wish my mother had been admitted. She died within a week from the cause I feared, a slow brain bleed…there were signs but there was inadequate testing and he brushed off her recent history.

Erring on the side of caution is the right thing to do. Cost is not your problem or your responsibility, providing optimal care is. I don’t buy the argument that hospitalization should be refused based on what is good for the aggregate. Shouldn’t you be caring for the one patient and not the many?