The Flexible Threshold of Health Care
www.drvinayprasad.com
The Flexible Threshold of Health Care
Hospitalization & Intensive Care thresholds are fluid
I thought this was obvious stuff, but perhaps just for those of us who follow health care policy? 18 months without in person human connections predispose to rage, it seems. Check it out….
@Farzad_MD @DrBapuPod It may be worth doing a deeper dive at the preprint the article @VPrasadMDMPH linked to. Good idea. On the general point as to whether capacity influences admission decisions, I’m surprised by the reactions. I don’t see this as a controversial point. 1/n
@Farzad_MD @DrBapuPod @VPrasadMDMPH 2/ Many hospitals have short term capacity problems and it’s very common for hospital administrators to ask doctors to identify patients who can be discharged early, maybe with some additional home support. Bottom line, when there is a capacity crunch, people get discharged early
@Farzad_MD @DrBapuPod @VPrasadMDMPH 3/ Same thing happens in ICUs. If sicker patients need beds, less sick patients who would o/w have remained in the unit get sent to the general floor. Same principle. I am aware of one unpublished study that looks at scheduling decisions of surgeons
@Farzad_MD @DrBapuPod @VPrasadMDMPH 4/ for elective procedures and finds that the likelihood a surgeon decides to schedule a patient for a surgery (vs conservative management) depends on availability in that surgeon’s schedule in the upcoming weeks. Again, same idea.
@Farzad_MD @DrBapuPod @VPrasadMDMPH 5/ So I don’t know why there is pushback against hospital admission decisions being fluid and a function of bed capacity. There is so much medicine that is gray ie not black/white, I don’t know why this surprises people.
@Farzad_MD @DrBapuPod @VPrasadMDMPH 6/ The broader point that was being made was that measuring trends in Covid hospitalizations *could* be challenging if criteria for hospitalization is not static. I thought that was an important insight. I don’t know if that is a first order, second order, etc issue though.
@Farzad_MD @DrBapuPod @AnupamBJena Some of the reactions here seem a bit overwrought. There is evidence that physicians’ admitting decisions are influenced by the financial interests of hospitals with whom their group has a business relationship. Shouldn’t be terribly surprising.
Ex:
nber.org/system/files/w…
@Farzad_MD @DrBapuPod @AnupamBJena There's been studies on this over decades. An early one came from an interesting natural experiment at MGH when a nursing shortage led to a fall in ICU beds from 18 to 8 (!). Severity of illness in the ICU rose (less patients in ICU for monitoring only)
nejm.org/doi/full/10.10…
@Farzad_MD @DrBapuPod @AnupamBJena Although Milton Roemer basically emphasized the broader point going back to the 1950s. That being said, I think issue is that phenomenon is less a top-down "decision" as it is the aggregate consequence of decision-making by many clinicians under conditions of finite bed supply.
@awgaffney @Farzad_MD @DrBapuPod @AnupamBJena Anyone who has been the overnight resident in a MICU in a busy city hospital knows intuitively that this is correct. When beds are open, you keep patients an extra day "just to be sure they are OK". When beds are tight, admission to the ICU requires intubation and pressors.
