Hospitals need internists with a broader view (and functions)

@varelalaf

Internal medicine is a speciality of long tradition and the mother of almost all non-surgical specialities, so what is expected of it is to provide a general vision in the hospital care of complex patients. The internists are formed under the principle that no adult clinical issue is foreign to them, although they cannot cover in-depth all the knowledge and techniques that are available to modern medicine, so they should lead, more than they do now, multidisciplinary teams, to offer complex patients comprehensive care, instead of having to suffer the sum of multiple often uncoordinated actions.

ICUs and the elderly

There is concern about the misuse of hospital resources by the elderly, assuming that in many circums-tances, the services received, apart from being disproportionate, may also be more harmful than beneficial. The last post analysed the syndrome of post-hospitalization, a pathology that contracted the vulnerable people by the fact of them having been admitted to a hospital. In the same vein, I would like to comment on a clinical trial carried out in 24 French hospitals, with more than 3,000 people over 75 years of age in a clinically critical situation, of which half entered a program that promoted ICU admission , while the other half simply followed the standard criteria of each centre, without any external pressure. In the observed results, the patients in the intervention group logically entered the critical units (61% versus 34%), but this did not lead them to live longer, since, despite the fact that the gross mortality at 6 months was higher in the group that had observed greater use of ICUs (45% versus 39%), after adjusting the numbers*, relative risk was reduced to 1.05 (not significant).

Inappropriate use of large healthcare structures

The healthcare system has many resources that can be used appropriately, or not. Think of the child with fever who leaves the paediatrician’s office with a prescription of antibiotics, the elderly lady who ends her days in an intensive bed, when, in their case, a palliative action would have been more appropriate or the person with a moderate headache, without other neurological manifestations, which, by insistence, ends up undergoing a tomography. George Halvorson, in "Health care will not reform itself", echoes an investigation that, after reviewing 5 million medical records, concluded that waste due to clinical practices that don’t add value could be considered to reach at least 25% of the total health expenditure.

This waste affects practically all areas of healthcare, but now I would like to focus on what happens with the inadequacy of the use of large health structures: operating theaters, emergencies units, intensive care units, wards and primary care.

Hospitals: 10 necessary structural reforms

Hospitals are structures that generate a powerful influence on the overall health system. Their effectiveness in the resolution of certain acute diseases, especially surgical, gives them a great social prestige. This fact should not, however, hide two structural problems that are burdening their perspective:

a) The first problem is internal. Bureaucracies themselves are showing signs of fatigue and this affects the quality of services, especially in the safety of admitted patients.

ICU: the elasticity of demand

The intensive care units are the most expensive health system resources, and it’s logical that both the funders and the general public wonder whether the way these are used meets their full potential. But, despite this interest the data in this area are sadly rather scarce. Of the few that I have had access to, I will highlight two: a) the variations are impressive: in the US the cost of ICU represent 1% of GDP, while in the UK only 0.1%, ten times less b) misuse, or if you prefer - therapeutic obstinacy towards the end of life of people with chronic diseases- is detected; continuing in the United States, it’s estimated that between 13% and 35% of chronic patients die in an ICU, or they die in a hospital bed after being admitted to the critical care unit (J. Wennberg. Tracking Medicine. Oxford University Press, 2010).

Two intensive carers at the University of Pittsburgh, Dr. Rebecca Gooch and Dr. Jeremy Kahn, published in JAMA a conceptual model on the elasticity of demand for ICU admissions. In a 2x2 table they’re showing the severity of the disease crossed with  the chances of survival.

Hospitals: 10 necessary structurals reforms

Hospitals are structures with a powerful influence on the overall health system. Its effectiveness in solving certain acute health problems, especially in the surgical area, gives them a major social prestige. However this fact should not undermine two structural problems that are weighing their image down:

a) The first problem is internal. The own bureaucracies are showing signs of fatigue and this affects the service quality, especially when it comes to the safety of admitted patients.

b) The second problem is relational. The hierarchical superiority of hospitals has placed them apart from the communitarian reality and the primary care, and causes now a serious difficulty in dealing, in an integrated manner, with the complex chronic disease care and with the geriatric frailty.