Tuesday, March 30, 2010

What a Difference a Little Time and the Right Goals Can Make

In a new article in the Journal of Hospital Medicine, David Mitchell, a hospitalist at Akron General Medicine Center, presents a superb example of the impact on healthcare costs clinicians can make if they’re willing and able to spend the time to do careful diagnosis and conservative testing/treatment.

His example is “an elderly woman who presents to the emergency room with syncope occurring at church.”

Hospitalist 1 “takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days.”

Total Cost: $935
Level 4 emergency room visit $745
Level 4 internal medicine consultation $190

Hospitalist 2 “tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt-table test scheduled.”

Total Cost: $18,749
Level 4 emergency room visit $745
Level 3 history and physical $190
Laboratory evaluation: CBC, CMP, cardiac panel, urinalysis, D-dimer $843
EKG $150
Head CT $1426
Chest CT angiogram $2120
Brain MRI $3388
Echocardiogram $687
Carotid ultrasound $911
Level 4 neurology consult $190
Subsequent visits day 2, day 3 $150
EEG $520
Level 4 cardiology consult $190
Nuclear stress test $1359
Specialist subsequent visits $150
Telemetry bed, 3 days $3453
Discharge, low-level $90
Cardiac event monitor $421
Tilt-table test $1766


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