8. Using Data to Identify Opportunities for Improving Care for Patients

Mervin is a 52-year-old man with a history of substance abuse who arrives at the emergency room after having a fever for a couple days, along with shortness of breath. He complains that his heart feels like it is racing and he has trouble breathing, feeling like he just can’t get enough oxygen into his lungs. His blood is drawn, and within a few hours he is admitted to the hospital with presumed sepsis resulting from community-acquired pneumonia. He is started on antibiotics but continues to have intermittent fevers, tachycardia, and shortness of breath, requiring oxygen after two days. Due to consistently low levels of potassium and magnesium, his blood work needs to be monitored at least twice daily, and nurses have trouble finding a vein each time. Because of this, he has a peripherally-inserted central venous catheter (“PICC” line) inserted, allowing him to not be ‘stuck’ anymore. After a few days of antibiotics, IV fluids, and supplemental oxygen, he starts to improve and is discharged after six nights in the hospital.

Our take: Mervin’s course was a little complicated by factors that are likely largely outside of the control of his clinicians. His costs may be higher than expected for community acquired pneumonia, but many would argue this is warranted since he requires more frequent lab monitoring and had abnormal vitals beyond 48 hours. Common potential sources of variation in costs for a hospitalization like Marvin’s could be whether physicians decide to “broaden” his antibiotics (which could be much more expensive), the frequency of his lab draws, his level of care (ICU versus acute care) and any additional testing.

Joshua, a 63-year-old man with chronic unmanaged diabetes, obesity, and high blood pressure, arrives at the hospital after discharging himself from a long-term care facility about a week ago. He has been living off-and-on with family members, on the street, and in care facilities for years, rarely taking his prescribed medications. He has also been complaining about tingling and burning pain in his left foot that lately has become numb and with ulcerated skin. He was admitted to the hospital due to abnormal lab work, high fever, low blood pressure, and a severely infected foot. He underwent an MRI that showed he has osteomyelitis (a bone infection) of his left metatarsal. The vascular surgeon evaluated the patient and decided he needed an operation but could not schedule him until Tuesday (5 days after admission).

Joshua remained on the hospital medicine service and continued on IV vancomycin and zosyn for 5 days. He then went to surgery and had a transmetatarsal amputation. He was continued on IV antibiotics for two more days after the surgery and then was discharged to a rehabilitation facility.

Our take: Joshua is a complex patient with multiple comorbidities. However, his care was even more expensive than it needed to be, mostly related to the delay in obtaining his needed foot surgery. If this is a common finding, the hospital may want to target this opportunity area to improve efficiency with surgical scheduling and availability, potentially decreasing costs while improving quality of care and patient experience.

Jane is a 27-year-old woman who has been feeling generally unwell for about 3 or 4 days with symptoms of a urinary tract infection. She visits an urgent care center near her house when she suddenly feels worse and her temperature spikes. At the urgent care clinic, she seems to have left “CVA tenderness” (tenderness at her back at the location of her underlying left kidney), and her blood is drawn. An abnormal CBC lab test, her spiking fever, and tachycardia (increased heart rate) results in her physician sending her to the emergency room immediately. There she is admitted and quickly receives IV antibiotics and some IV fluids. She feels better after about 24 hours and continues to improve. She is released two days later with oral antibiotics and she continues to rest at home.

Our take: Jane’s case is straightforward. She is young, healthy and will likely recover quickly after finishing her oral antibiotics. The biggest source of potential variation in a hospitalization for a patient like Jane would be the length of stay. The physicians here presumably did a good job by discharging her from the hospital as soon as clinically safe and providing an outpatient management plan for her infection.