Why is Quality Improvement important in Healthcare!
Being a former student of Dr. Lucian Leape at Harvard School of Public Health, I understood under-utilization and over-utilization of health services but did not expect to have a first hand experience of both at the same time.
Last week, my husband was diagnosed with ureteral lithiasis (renal stones) with bilateral renal calcifications and obstructive renal nephropathy which led to our tryst with one of the great healthcare systems of the world.
We work in different cities of the US and meet only on the weekends when my husband visits home in Jersey City. During the weekdays, he stays at Madison, WI. One fine Friday morning, I received a call from him. His voice was shaky as if in deep pain. He had experienced a sudden onset excruciating pain in left lumbar region. (It was a déjà vu. I have had 2 similar calls from him in the past- one in 2006, for right sided pain that was suggestive of appendicitis for which he had an emergency appendicectomy and another even further back for renal colic.) He is a very tolerant man and the fact that he never ever complains about a pain that is not due to an emergency condition made me worry. This time, his symptoms were suggestive of renal colic because of possible obstructive stone in the left kidney. I advised him to go to the Emergency for pain medication and further work up. He was given some strong iv pain medication(probably morphine family), the name of which was not mentioned in discharge summary. In fact, it should not be called a discharge summary as it was merely a prescription. His routine investigations and X-Ray was done. But, all he was told was that he had microscopic hematuria and he had a renal stone. No reports were given with discharge. Wasn’t there a need to know detailed findings, as in what was the size and location of the stone and whether it was affecting the renal organs in any way? I was surprised that no investigations were handed to him for future follow ups. All they cared to do was hand off a prescription asking to follow up with his PCP (who was in Jersey City) after 3 days.
His pain improved by the evening and he flew back to home with some discomfort. We spent a restful weekend. Monday morning, he took a flight to Madison for work, hoping that the coming week would be uneventful. To our dismay, the pain occurred again while he was in transit, this time making an even grand appearance. He was trembling in pain and had an episode of vomiting. Fortunately, the flight was about to land in Cleveland. All passengers were requested to remain in their seats because of this emergency. When the flight landed, the ambulance was waiting for him by the runway. He was rushed to the emergency soon after landing. (Great job! I must tell Dr. Atul Gawande that once again aviation industry beat health care in quality and efficiency.)
I received another call from him when he was in emergency room. Alas! If only I could be there to save him some trouble! Since, he did not have any previous medical records apart from the discharge prescription, all routine investigations were repeated and a CT Scan was done. I asked him to insist on receiving the reports at discharge this time. Thankfully, upon insisting he was given all reports but the CT Scan film. He improved by the evening and returned to home instead of taking a connecting flight to Madison. I rushed from office to the airport to pick up my dear husband who was still in pain.
Next day, I took him to our Primary Care Physician (PCP) for specialist referral. Thanks to the over-engineered system that specialist referral was not an easy task. One has to go through a gatekeeper.
The PCP asked for the CT Scan and XRay film. Guess what! We did not have it. The credit goes to the emergency room protocol where it is not considered necessary to provide all reports to the patient upon discharge. The PCP repeated URM and found some leukocytes. An antibiotic cover should have been prescribed earlier at the emergency but for some reason they didn’t. Probably they believed in ‘Eminence Based Medicine’ more than ‘Evidence Based Medicine’.
My husband had to take a flight to India in 3 days to attend a family function for which he had been waiting for a long time. Hence, we requested for an earlier referral to confirm if he was fit to fly. The PCP asked us to come for a follow up visit after 3 days while he would check if a specialist appointment was available. We showed up at the health center for the scheduled follow-up visit, (the same day that he had his long distance flight). To our dismay, the referral could not be arranged due to scheduling conflicts (under-utilization). The PCP ordered for a repeat CT scan. It was extremely difficult to get same day appointment for CT Scan from the OPD. Hence, we were asked to go to the emergency.
When we went to the emergency, I provided the entire history and reason for the visit to the registrar. Since we were referred to the ER for CT Scan while my husband was stable (as it was a very long wait before we could get a scan done from OPD and we needed it before his flight in the evening), we were willing to pay the extra copay for the scan. After an hour long process for registration and yet another hour of wait, I was finally able to speak to the Emergency room doctor on duty. Despite explaining everything to her, she had ordered unnecessary blood investigations and iv infusion just for the sake of following ER protocol (over-utilization). Another hour passed and no one showed up for next steps. After a couple of reminders, a nurse came with iv line equipments.
This was the limit. My husband was up and about and all we needed was a CT scan to see how his kidneys and the stone were doing in order to be able to decide whether he was fit for a long distance flight same evening. I had to step forward to stop the nurse from repeating those unnecessary procedures. Fortunately, I was a physician myself and was able to control some of the process to some extent. I am wondering what would the patient journey be like for people with non medical background. In our case, had I not stepped forward, there would have been unnecessary pricks, infusion and observation (over-utilization). Not to mention the side effect of missing the flight.
Finally, we got his scan done and were able to get a cd for the CT Scan report upon special request. Fortunately, the kidneys that were swollen earlier had reverted back to normal and the size of stone had decreased from 4mm to 3mm. There was another non-obstructive stone identified in the right kidney. Frustrated, my husband took his flight to India hoping to recover soon and praying for no more ER visits. However, he would still need a couple of follow ups, a specialist referral and investigations to find the etiology for prevention in the future.
This short experience was long enough to reach a conclusion that healthcare needs quality improvement. There are a couple of things that could have made this experience smoother and are the potential areas for healthcare quality improvement.
1. Whenever, a patient is discharged from ER, s/he should be given a complete history of stay along with all investigations report.
2. For radiological investigations, if actual film can’t be given, cd consisting of scan images should be handed to the patient.
3. Ideally, the EMRs and HIS for individual hospitals should talk to each other. If not, then at least a detailed, legible description of the stay at hospital emergency room, should be provided to the patient for future reference.
4. Sometimes, instead of following protocols blindly, understanding the patient’s needs may yield better results. For example, in the incident mentioned above, there was no need of blood investigations and iv infusion. Not only would it have incurred unnecessary costs but it would have added to patient’s discomfort and recovery time.
5. On the other hand, there should be proper protocols where needed. For instance, in the case above, prophylactic antibiotics should have been prescribed when there was urinary stasis due to stone.
6. Wait-time for appointments for radiological investigations like CT Scan or MRI should be shorter.
7. Specialist consultation should be made easier. Where self referral to specialists has a disadvantage of increasing cost for health insurance companies, difficulty in referral may result in patient anguish and sometimes even worsening of conditions.
The crux of the matter is that there is a need of health care optimization where underutilization is balanced by resources saved from avoiding overutilization.
(Note: The difficulty in navigating through the health care system and high costs are one of the major reasons why people are getting attracted towards medical tourism where the marketing teams make the health care navigation easier for patients by providing good support services. But the sad part is that no matter where they go, the quality has a lot of scope for improvement.)
-Jaya Sonkar MBBS, MPH
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