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Practicing cost-effective medicine

One clinician's top 10 tips

By Robert M. Centor, FACP

From the September ACP Hospitalist, copyright © 2007 by the American College of Physicians

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We all want to practice cost-effective medicine. But cost-effective medicine isn't a product of cost-effective analysis, and it's important to understand the difference. Cost-effectiveness analyses inform public policy. When we care for individual patients, however, our first goal is to practice the most effective medicine possible. In that context we hope to minimize costs, but not at the expense of providing appropriate care. The following list represents my suggestions for practicing cost-effective hospital medicine.

1. Before ordering a test, always ask yourself how the results will change the overall management plan. We can save a lot of money by not ordering unnecessary tests. For example, we know that anterior carotid disease does not cause syncope, yet I often see housestaff order carotid Doppler ultrasonography for a patient who has suffered syncope. Unnecessary tests add costs and increase length of stay. Consider whether the test really needs to be done during the current hospitalization.
2. Start planning for discharge at the time of admission. You can save one or more days of hospitalization when you anticipate discharge rather than have discharge surprise you. I recall the famous Lewis Carroll quote:

   One day Alice came to a fork in the road and saw a Cheshire cat in a tree.
   "Which road do I take?" she asked.
   "Where do you want to go?" was his response.
   "I don't know," Alice answered.
   "Then," said the cat, "it doesn't matter."

   The best hospitalists, for example, anticipate nursing home placement or the need for home health equipment. If the patient will need home oxygen, start working on making arrangements as soon as possible.
3. Order consults like you order tests. Many subspecialists, when called, will order a shopping list of tests. Remember what Maslow said: If the only tool you have is a hammer, you tend to see every problem as a nail. Refrain from consultation unless you need a procedure, or you're totally confused and thus need a fresh opinion. Likewise, learn which consultants think about the patient and the patient's problem and which consultants order tests reflexively. Learn when a simple telephone call can resolve the need for a consultation.
4. Use older, generic drugs when you can. When you have culture data, simplify your medication regimen. Too often patients are started on broad-spectrum antibiotics appropriately, but the housestaff and attendings don't switch to targeted antibiotics after culture results would inform that change. Use as few drugs as the patient really needs. Each additional drug adds a risk of interactions and side effects. Reconcile medications in the hospital.
5. Learn and embrace the principles of palliative care. For example, ordering a percutaneous endoscopic gastrostomy (PEG) tube should require extensive discussion with the patient or, if the patient cannot communicate, the family. Don't keep patients in the ICU because they are very sick; keep them in the ICU if they are very sick and you expect significant improvement, which will allow a satisfactory quality of life. Learn how to control pain. Know the availability of home hospice services in your community.
   We need to take time with the patient and/or family to determine what goals we want to achieve. Many patients and families want and expect comfort care, rather than heroic futile care. Work to meet the patient's needs, that is, treat the patient, not the disease.
6. Understand the difference between an inpatient evaluation and an outpatient evaluation. You don't need to solve every problem during hospitalization. Talk with your outpatient counterpart and let him or her complete the evaluation.
7. Make certain that transitions are crystal clear. This includes transitions between inpatient and outpatient care (that advice goes both ways) and transitions between inpatient physicians. Make certain that the discharge medication list is clear to the patient and the physician who will receive the patient.
8. Get old records, and don't repeat tests unnecessarily. Too often, we repeat expensive testing because we only trust our own hospital records.
9. Invest your time in patient education. Make certain that the patient understands and agrees with the diagnostic and treatment plan. Involve the patient in discharge planning. Explain the rationale for each drug in his or her armamentarium. Reconcile discharge meds and note any changes from former meds. Make certain that the patient understands what symptoms or signs should trigger hospital return.
10. Educate the relevant family members. This depends on the patient. Many patients want close family members to understand their problems. When patients agree, we should work to make family expectations realistic. Find out which family members will take an active role after hospitalization. When necessary, involve those family members in your decision making.

Remember that each day in the hospital puts the patient at risk for iatrogenic disease. Remember that each test causes some discomfort. Most of all, remember to use common sense. Applying the tips on this list—and adding your own—will help you decrease costs and improve effectiveness.

Dr. Centor is an academic general internist at the University of Alabama School of Medicine and a frequent ward attending at the Birmingham VA Hospital. Read his blog at www.medrants.com.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated