Some hospital doctors and administrators say the quality of care they are able to offer is under siege by an insider group no one would expect: patients.
Dr. Daniel Durand, a radiology resident at Johns Hopkins Hospital in Baltimore, said a class of patients, dubbed “bogus admits” by physicians, are admitted through the emergency room when it is not clinically justified.
Patients like Irena, whose name has been changed to protect her privacy, frustrated Dr. Durand when he began practicing at Hopkins last year as a general medicine intern. Irena arrived at the ER complaining of chest pains and shortness of breath. A few hours later, she was admitted to a general medicine ward, and it fell to Dr. Durand to determine whether she had suffered a heart attack. He quickly realized she had been hospitalized for a case of heartburn.
Instead of getting a restful night’s sleep at home, Irena was subjected to extensive medical work-ups and faced exposure to hospital-borne illnesses. As for financial ramifications, Irena, her insurance company or the government likely would receive a much larger bill. Because Dr. Durand had to write notes, orders and assessments on Irena, he spent less time looking after his other patients.
Dr. Durand said there is no easy way to address the problem.
“Doctors are held to such an exacting standard by the public and the law that they act very conservatively and want to admit too many people to the hospital,” Dr. Durand said. “This drives the cost of care up and strains resources so that we can do less of what we do well: treat disease.”
A private-sector hospital study by the Michigan Health Care Education and Research Foundation in 1987 reviewed a random sample of patient records from 21 hospitals in southern Michigan. Of the 1,226 records examined, 430 revealed erroneous patient admissions, suggesting that 35 percent of the admissions were clinically unnecessary.
Rates of improper admissions in publicly funded hospitals are even higher. An Iowa Health Services Research and Development Field Program study in 1991 found that 43 percent of medical/surgical admissions to Veterans Affairs hospitals were unnecessary. This study reviewed 6,063 patient medical records from a random sample of 50 Veterans Affairs hospitals from across the country.
Dr. Peter Hill, clinical director of the Department of Emergency Medicine at Hopkins, said a review of ER doctors’ decisions to admit patients amounts to a medical version of Monday-morning quarterbacking.
“It’s a problem with perspective,” said Dr. Hill, who has served on the faculty since 1998.
Lab results and medical records can make it clearer that the patient is not at risk, but they often are not available before the patient must be moved out of the ER.
Irena had mentioned to a physician’s assistant that her family had a “history of heart disease,” Dr. Durand said. Although her symptoms fit a non-cardiac cause - chest pain that worsened when lying down and was exacerbated by spicy foods - the physician’s assistant admitted her based on the family history.
Dr. Durand later discovered, however, that Irena’s “family history” consisted of several distant relatives who died in their late 60s and early 70s. This suggested the physician’s assistant had attached too much weight to what Irena had said, but is “bogus admission” an accurate label here?
Criteria-based instruments are designed to help Medicare, Medicaid and insurance companies determine retrospectively whether to pay for services, Dr. Hill said, but give ER physicians no clear explanation of the criteria parameters for admission.
Dr. Hill cites another line of defense: the grow ing number of ER observation units at U.S. hospitals over the past 20 years. One was created at Hopkins in 2001 to buy additional time to monitor patients.
The 16 beds in the unit at Hopkins hold 4,000 to 6,000 observation patients in a given year, Dr. Hill said. Once additional information can be gathered on the patient, 75 percent are discharged without being admitted.
By creating arbitrary clinical thresholds, Medicaid, Medicare and insurance companies may have made it harder for ER doctors to stave off unnecessary admissions, Dr. Hill said.
ER observation units have reduced the number of one-day admissions, which often are perceived as bogus admits. Dr. Hill said this drop had a negative impact on the quality-of-care reports for other departments because the removal of one-day admissions caused a spike in length-of-stay averages for general medicine. He said the hospital administration then asked for a return of one-day patient admissions.
“We did it; the ER helped them,” Dr. Hill said.
How? By agreeing to admit more patients with borderline chest pain to inpatient care. The hospital administration was asking Dr. Hill to admit a patient group that had regularly been labeled as “bogus” - patients like Irena.
This move appears to have a financial incentive as well. Maryland is a capitated state - meaning insurers pay essentially the same for chest-pain patients whether they stay for one day or five - so the loss of one-day admissions was taking a toll on the hospital’s bottom line.
The debate over whether erroneous admissions are legitimate concerns is creating conflicting approaches to care. ER doctors have the power to admit, just not the time to fully diagnose, whereas the internal medicine doctors have the time needed to properly diagnose a patient, but not the ability to choose whom to admit.
Dr. Hill said ER doctors need flexibility in determining when to admit patients to their own observation units and that removing thresholds to pay for care would make economic sense.
Studies suggest that placing patients with chest pain in observation units instead of admitting them to the hospital saves about $500 to $1,200 per patient.