CEO 1.1 Patient Care: Approach the care of a patient as a cooperative endeavor , integrating patients’ concerns, and ensuring their health needs are addressed.
1.3 Use the best available information to develop patient care plans that are cost effective and utilization of diagnostic tools and therapeutic interventions appropriate for each unique patient and/or patient population and that are delivered in a compassionate, safe and error-limited environment.
During M2 year in a LG session, I was introduced to cost effective care. In the group activity, we were presented with a patient with a suspected pulmonary embolism. The assignment was to decide which diagnostic tests were appropriate. A list of interventions was provided, along with their associated costs. As a group, we decided to do quite an extensive and expensive workup for our patient. Our preceptor advised us to carefully choose interventions using the principles of specificity and sensitivity and evidence based medicine to guide our decisions.
During my M3 year, I was able to see more examples of cost effective care such as: not ordering every set of labs everyday if it was not clinically indicated; and ordering albumin with an end date for a specified amount of time so that the provider could assess whether the expensive intervention was necessary to continue.
During my hospitalist medicine elective, I was able to help address patient concerns. There was a patient with a history of recurrent urinary tract infections and a suprapubic catheter who had been admitted with sepsis secondary to a urinary tract infection. After initiating broad-spectrum antibiotics, the patient was improving clinically as evidenced by the absence of fevers and decreased white blood cell count. Once the urinalysis results returned with the susceptibilities, the antibiotics were changed to target the pathogens. The plan that day was to discharge the patient to the assisted living facility where he lived.
The night after the antibiotic was changed, the patient had an episode of emesis and shortness of breath overnight. The following morning, I sat with the patient to ask him about this episode. I took the time to listen to him when he expressed how scared he was following this episode. He suspected his new antibiotic caused the reaction. Given the patient had a history of adverse effects to medications, my attending and I decided to change the plan and keep the admitted patient another day. Fortunately, after keeping the patient there for one more day, he was not observed to have any other adverse reactions to the medications.
From this experience I learned the importance of allowing a patient to help determine the medical plan. The technique I implemented during the shared decision- making process was the SHARE approach. While the patient was no longer septic, he knew he did not yet feel comfortable going home. I have been taught that the patient is in charge of their health. If this is truly to be believed, it is important to allow the patient to be a part of the decision- making process that directly involves their health. By presenting the patient with the option of either going home or delaying discharge for a day, we encouraged the patient to be an active participant in his health.
SHARE Approach to Decision Making
When the patient was ready to be discharged, I was reconciling his medications with my attending. There was a new medication he had been prescribed during his stay to help with bladder spams and his leaking urinary catheter. Before deciding if the medication should have been continued at discharge, I looked up how many times the medication was used during the hospital stay to decide if it was appropriate to prescribe the patient the medication on discharge. I could see the patient did not use the medication during his hospital stay. I also looked up the price of the medication using GoodRx. After seeing the patient had not used the medication during the hospital stay and the high cost of the medication, I reasoned it was not necessary to get the prescription filled at the pharmacy.
https://www.goodrx.com/go/homepage-lander-sem-6?c=homepage-lander-sem-6&gclid=CjwKCAiA1eKBBhBZEiwAX3gql5iOqzcQUe4ZTmT3dMaDpXWSEO6eRWmS7ITsuAQhWv7QMFw1021CrRoCrzgQAvD_BwE
GoodRx Website
This experience allowed me to utilize cost effective measures when making medical decisions. It is important to think about each medication that is prescribed to a patient upon discharge. A medication should never be continued simply because it was prescribed during the inpatient stay. Unnecessary medication costs inflict a financial burden to patients that should not be taken lightly.
As an intern, I want to be able to include the patient in the decision -making process. It is my job to present them with the options so that they can make the most informed decision. I will also continue to evaluate if a medication needs to continue to be used or if it can be discontinued due to clinical improvement or not needing the medication.
Citations
The SHARE Approach: A Model for Shared Decisionmaking – Fact Sheet. Content last reviewed September 2020. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/health-literacy/professional-training/shared-decision/tools/factsheet.html