2024-01-19 15:57:04
welcome to Impact Factor, your weekly dose of commentary on a new study in medicine. I am Dr. F. Perry Wilson from the Yale School of Medicine in New Haven, United States.
Dr. F. Perry Wilson
The first time I saw a patient in the hospital was in 2004, twenty years ago, when I was a third-year medical student. I mean, look at that guy. The things he could tell her.
Since then I have spent countless hours at the hospital as a resident, nephrology fellow, and finally as an attending. And I’m sure many of you in the medical community feel the same way I do and that is that patients are much more complicated now than before. I listen to an intern present a new case on rounds and she has an evaluation and plan that covers a dozen individual medical problems. Sometimes I literally have to ask myself, “Wait, why is this patient here again?” But until now I had no data to convince me that this feeling was real: that hospitalized patients are becoming more complicated or that they only seem more complicated because I am getting older. Maybe I was better able to keep track of things when I was an intern than I am now as an associate, spending only a couple of months a year in the hospital. After all, if patients were becoming more complicated, surely hospitals would know this and allocate more resources to their care, right?
It is not an illusion. At least not according to a recent article published in JAMA Internal Medicine examining hospital admissions spanning approximately 15 years in British Columbia, Canada.[1]
I like this study for two reasons: first, their electronic medical records system covers the entire province, so they have no problem getting data from hospital A versus hospital B. All the data is there: in this case more than 3 million British Columbia non-elective hospital admissions. Second, healthcare is universal. We don’t have to worry about insurance companies changing or a new government program starting. It’s just a cleaner system.
Of course complexity is difficult to define and the authors decide here to examine a series of parameters that I think we agree are related to complexity. These include aspects such as patient age, comorbidities, medication, frequency of hospitalization, etc. They also analyzed the outcomes associated with hospitalization: Did the patient need to go to the intensive care unit? Did he survive? Re-entry?
And the objective comparison is as clear as the British Columbia air: in the last 15 years the average hospitalized patient is about 3 years older, is twice as likely to have kidney disease, has 70% more diabetes, is under treated with more drugs (especially anticoagulants) and are much more likely to be admitted to the emergency room. He has also spent more time in the hospital in the last year.
Given the greater complexity, it would be expected that the results for these patients would be worse than years ago, but the data do not confirm this. In fact, in-hospital mortality is lower now than 15 years ago, although mortality 30 days after discharge is higher. If we put this data together, it turns out that the mortality rates are quite stable: 9% of people admitted to the hospital for non-elective reasons will die in the following 30 days. What happens is that nowadays we tend to discharge them before that happens.
Why are our patients increasingly complex? In part it is due to their demographic characteristics; After all, the population is aging. Another part is related to the increasing burden of comorbidities such as diabetes and kidney disease associated with the epidemic of obesity. But in a way, we are victims of our own success. Today we can keep people alive who would not have survived 15 years ago. We have better treatments for metastatic cancer, less invasive treatments for heart disease, and better protocolized care in the intensive care unit.
Given all this, does it make any sense that many of our hospitals are skeleton staffed? That hospitalists say they see more patients than ever?
Lately there has been a lot of talk about burnout among healthcare professionals. Perhaps we need to start recognizing—especially those who haven’t practiced on the clinical front for a decade or two—that the work is simply harder now. As patients become more complex we need more resources, human and otherwise, to care for them.
Dr. F. Perry Wilson, MSCE, is an associate professor of medicine and director of the Yale Clinical and Translational Research Accelerator. His science communication work can be found on the Huffington Post, on NPR, and here on Medscape. His new book, How Medicine Works and When It Doesn’tIt is now available.
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