The costs of over-hospitalization

This week on surgery I have a charming, but somewhat demented, 81 year-old retired lawyer who I saw two days ago during a pre-operative exam for an inguinal hernia. The hernia was reduced - meaning that there was not protrusion of the abdominal contents through the wall - and his surgery was elective (most hernias, by the way, do not require surgical correction unless the bowel is involved or there is intolerable pain). It turns out that he was anemic on routine blood test and he reported dark stools for several months. He also has a history of colon cancer (with surgery some years ago) and has had polyps removed during several different colonoscopies. We decided that the hernia repair should be delayed until the cause of anemia was investigated further, thinking obviously that he probably has some chronic GI bleeding, and possibly a recurrence of the colon cancer.

He was admitted to hospital and transferred to the medicine hospitalist team for work up of the anemia, and was given 4 units of blood. Indeed the cause of his anemia needs to be explored, but it is not critical that it be done in the hospital. Unfortunately he has now been in the hospital for 5 days, when the workup could have been done as an outpatient. This would have cost significantly less money and would have been much more pleasant for that patient, and avoided the risks of getting a nasty infection. He has been very cooperative and pleasant so far, but today he admitted to be impatient because he wanted more activity and the hospitalist team wrote orders that he must be accompanied for any ambulation (phooey, if you ask me).

I don't know why we lose sight of the big picture in medicine. Too often I have noticed (especially with residents) that we are too intent on keeping people hospitalized and over-managing their medical issues. "The guy is anemic! We must keep him in the hospital until his anemia is stabilized," the hospitalist replied when I asked when he was planning to discharge the patient (although to be fair, hospital admission stays are drastically shorter than they used to be, and there is much fear of lawsuits). I am sceptical of how much good we really do for patients by keeping them in the hospital with all these lines, tubes, tests, needles sticks, vitals checks and medicines that are usually ordered.

This guy is a good example of this typical story. His bleeding was not acute, he had been anemic for several months without having any symptoms, his condition was stable, he was functional and independent, he did not require nursing care. And yet, one day he was happily at home, then next - nothing had changed in between - he was in a hospital with all the economic and psychological costs that entails.