Map of life expectancy at birth from Global Education Project.

Thursday, April 02, 2009

Another buried lede

I don't know why the ink-stained wretches spell it "lede" instead of "lead," but anyway, here it is once again in the last paragraph of the story. (And once again, the day's health care news is in the NYT business section. Res ipsa loquitur.) The original study is not available to you common rabble but you can read the abstract if you like.

In a nutshell, 20% of Medicare patients who are discharged from the hospital are back in the hospital within 30 days, and a third are back within 90 days. Of those who are only out for a month, more than half had apparently not seen a doctor during that time. Now you might ask, "How much of this is actually avoidable?" And that would be a good question -- it's not necessarily a no-brainer that you could knock these numbers down by a whole lot. The answer is that in many cases, the hospitals don't do take some simple steps that would help, such as making sure the patients have adequate instruction and counseling about medication adherence and other self-care issues, that their primary care physicians are informed about what's going on and a visit is scheduled, etc.

Now here's the lede in the last paragraph: the hospitals have a strong financial incentive to make sure the people do come back, because that's how they make their money. Or, via NYT reporter Reed Abelson, "'Reducing admissions in a hospital is quite punitive in today’s environment,' said Dr. Amy E. Boutwell, a policy specialist at the Institute for Healthcare Improvement." Well, we certainly wouldn't want to punish hospitals for taking proper care of their patients. So here's the answer:

Do what the rest of the civilized world does -- you know, communist totalitarian dungeons like Canada and the United Kingdom. Put hospitals on a budget that reflects the cost needed to take care of the population in their catchment area, by keeping them as healthy as possible and sufficiently well-supported in the community that they don't need to be admitted more often than necessary. Then their incentive will be to do exactly that -- to keep people out, rather than bring them in. And believe me, the last place you ever want to be is a hospital. Hospitals are very dangerous places, filled with sick people with holes in them and tubes going into the holes followed by very nasty microorganisms that eat antibiotics for breakfast and get fat on them, and then come around and eat you.

We need universal, comprehensive, single payer national health care.


kathy a. said...

the link isn't working to the abstract, but it sounds like an interesting study.

you've got a couple of good hypotheses there: adequate counseling of patients before discharge, and the basic step of keeping primary physicians informed, which honestly doesn't happen well enough. i have a few more suggestions.

first, patients are often discharged asap, even before adequate arrangements are in place. hospital social workers are a godsend for contacts with needed services, but the hospital's involvement ends with discharge.

second, the problem isn't just elders and their loved ones floundering away in the absence of guidance. one of my biggest problems after my mother was discharged to a nursing home [after her stroke and broken hip] is that her primary care physician never once bothered to visit her. her orthopedic surgeon came in to deal with ortho problems, but she had lots more problems.

my mother ended up in the hospital within 30 days -- a different hospital, with a different attending. i honestly don't know if seeing a primary care doctor would have made a difference that first month, under her circumstances, but it would have saved us huge amounts of angst and might well have helped us handle the final weeks in a more thoughtful manner.

Cervantes said...

Good point. My mother is in a rehab facility right now, her primary care doc knows all about it, but he hasn't shown up -- even though his secretary told me he was going to.

Adequate discharge planning and making sure community services are in place, proactively, is obviously a major key. Hell, Medicare even pays for it, up to a point, so that's not the problem. The hospitals have no incentive, however.

robin andrea said...

It's a horror to consider that hospitals have an incentive to keep patients coming back. But as long as they are for-profit institutions it makes complete sense.

I have to say that even when there is some discharge counseling, if it doesn't come with clearly written instructions it's hard for patients to remember what they are supposed to do. Compliance is an interesting issue.

kathy a. said...

robin, you have a great point.

RayPublicHealth said...

Here is how the NYT explains why "lede" is spelled that way:

About The Lede
In the news business, the opening sentences of a story are referred to as its "lede" -- spelled that way, journalism lore has it, to avoid confusion with the lead typesetting that once dominated newspaper printing presses.