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Late last year, a study suggested that patients in the emergency department with a transient ischemic attack could be more cost-effectively treated by being sent to a neurology clinic for urgent evaluation, rather than being hospitalized for the 48 hours it takes for an average inpatient work-up (Neurology 2011;77:2082-8).
I entirely agree with this. The trouble is that these studies are always done at an academic institution and don’t take into account the nature of "trench warfare" neurology as it happens in private practice. I’ll point out some practical considerations.
How do you plan on getting a patient seen on the same day (or even the next day) after they went to the ED? Most neurologists are booked up at least 1-2 weeks in advance. I personally start seeing patients at 8 o’clock each morning (sometimes 7 o’clock) and don’t break for lunch. I work straight through. So where am I (or anyone else) going to put them in? I suppose some people might say, "Just send them over and I’ll squeeze them in," but (in my opinion) that doesn’t work very well. You just end up trying to see them AND the rest of the patients in a rush and do a half-assed job on all of them. Quantity of care is NEVER equal to quality of care, no matter how hard you try to make them the same.
The idea of doing the work-up as an outpatient is compelling but brings up its own issues that the article didn’t consider:
• Insurance. In the hospital, whatever you order gets done. But as an outpatient, you may have to go through several layers of authorization to get an MRI and MRA. This could include having to make a doctor-to- doctor authorization phone call and can take 1-2 weeks depending on the insurance. A lot more can go wrong in 2 weeks than in a 48-hour hospital stay.
• Convenience. You need an MRI, echocardiogram, and labs? Maybe an EEG in some cases? In the hospital, they all get done THERE. But for an outpatient, you need three to four different facilities. This will likely increase the time of the work-up and make it harder for the patient. The tests will have to be done on different days, and some people will have trouble arranging transportation.
• Compliance. Let’s face it – a hospital patient is a captive audience. Aside from watching daytime TV and eating, there’s not much else to do but go have tests done. But if you spread the tests out over 1-2 weeks, the compliance factor may drop dramatically. A patient may start to think in terms of "I feel fine today, so why do I need this?" or cancel the test to attend a grandson’s birthday party and then never bother to reschedule it.
Lastly, there are the legal issues. How many of you neurologists out there want it documented in the chart that you personally told the emergency medicine doctor to discharge a TIA patient for outpatient follow-up? How many of you can envision an ED doctor wanting to take the legal risks of writing that order? And, perhaps most important, how many of you can easily see yourself being cross-examined by Marty Malpractice, J.D., about why you ordered a TIA patient sent home who then suffered a massive stroke that night? All the literature supporting your position may not make you look good in those circumstances.
The only way I actually see this working out is with a national set of solid guidelines telling us to do this and tort reform to help protect the doctors who follow them. And let’s face it, neither is likely to happen in my lifetime.
Late last year, a study suggested that patients in the emergency department with a transient ischemic attack could be more cost-effectively treated by being sent to a neurology clinic for urgent evaluation, rather than being hospitalized for the 48 hours it takes for an average inpatient work-up (Neurology 2011;77:2082-8).
I entirely agree with this. The trouble is that these studies are always done at an academic institution and don’t take into account the nature of "trench warfare" neurology as it happens in private practice. I’ll point out some practical considerations.
How do you plan on getting a patient seen on the same day (or even the next day) after they went to the ED? Most neurologists are booked up at least 1-2 weeks in advance. I personally start seeing patients at 8 o’clock each morning (sometimes 7 o’clock) and don’t break for lunch. I work straight through. So where am I (or anyone else) going to put them in? I suppose some people might say, "Just send them over and I’ll squeeze them in," but (in my opinion) that doesn’t work very well. You just end up trying to see them AND the rest of the patients in a rush and do a half-assed job on all of them. Quantity of care is NEVER equal to quality of care, no matter how hard you try to make them the same.
The idea of doing the work-up as an outpatient is compelling but brings up its own issues that the article didn’t consider:
• Insurance. In the hospital, whatever you order gets done. But as an outpatient, you may have to go through several layers of authorization to get an MRI and MRA. This could include having to make a doctor-to- doctor authorization phone call and can take 1-2 weeks depending on the insurance. A lot more can go wrong in 2 weeks than in a 48-hour hospital stay.
• Convenience. You need an MRI, echocardiogram, and labs? Maybe an EEG in some cases? In the hospital, they all get done THERE. But for an outpatient, you need three to four different facilities. This will likely increase the time of the work-up and make it harder for the patient. The tests will have to be done on different days, and some people will have trouble arranging transportation.
• Compliance. Let’s face it – a hospital patient is a captive audience. Aside from watching daytime TV and eating, there’s not much else to do but go have tests done. But if you spread the tests out over 1-2 weeks, the compliance factor may drop dramatically. A patient may start to think in terms of "I feel fine today, so why do I need this?" or cancel the test to attend a grandson’s birthday party and then never bother to reschedule it.
Lastly, there are the legal issues. How many of you neurologists out there want it documented in the chart that you personally told the emergency medicine doctor to discharge a TIA patient for outpatient follow-up? How many of you can envision an ED doctor wanting to take the legal risks of writing that order? And, perhaps most important, how many of you can easily see yourself being cross-examined by Marty Malpractice, J.D., about why you ordered a TIA patient sent home who then suffered a massive stroke that night? All the literature supporting your position may not make you look good in those circumstances.
The only way I actually see this working out is with a national set of solid guidelines telling us to do this and tort reform to help protect the doctors who follow them. And let’s face it, neither is likely to happen in my lifetime.
Late last year, a study suggested that patients in the emergency department with a transient ischemic attack could be more cost-effectively treated by being sent to a neurology clinic for urgent evaluation, rather than being hospitalized for the 48 hours it takes for an average inpatient work-up (Neurology 2011;77:2082-8).
I entirely agree with this. The trouble is that these studies are always done at an academic institution and don’t take into account the nature of "trench warfare" neurology as it happens in private practice. I’ll point out some practical considerations.
How do you plan on getting a patient seen on the same day (or even the next day) after they went to the ED? Most neurologists are booked up at least 1-2 weeks in advance. I personally start seeing patients at 8 o’clock each morning (sometimes 7 o’clock) and don’t break for lunch. I work straight through. So where am I (or anyone else) going to put them in? I suppose some people might say, "Just send them over and I’ll squeeze them in," but (in my opinion) that doesn’t work very well. You just end up trying to see them AND the rest of the patients in a rush and do a half-assed job on all of them. Quantity of care is NEVER equal to quality of care, no matter how hard you try to make them the same.
The idea of doing the work-up as an outpatient is compelling but brings up its own issues that the article didn’t consider:
• Insurance. In the hospital, whatever you order gets done. But as an outpatient, you may have to go through several layers of authorization to get an MRI and MRA. This could include having to make a doctor-to- doctor authorization phone call and can take 1-2 weeks depending on the insurance. A lot more can go wrong in 2 weeks than in a 48-hour hospital stay.
• Convenience. You need an MRI, echocardiogram, and labs? Maybe an EEG in some cases? In the hospital, they all get done THERE. But for an outpatient, you need three to four different facilities. This will likely increase the time of the work-up and make it harder for the patient. The tests will have to be done on different days, and some people will have trouble arranging transportation.
• Compliance. Let’s face it – a hospital patient is a captive audience. Aside from watching daytime TV and eating, there’s not much else to do but go have tests done. But if you spread the tests out over 1-2 weeks, the compliance factor may drop dramatically. A patient may start to think in terms of "I feel fine today, so why do I need this?" or cancel the test to attend a grandson’s birthday party and then never bother to reschedule it.
Lastly, there are the legal issues. How many of you neurologists out there want it documented in the chart that you personally told the emergency medicine doctor to discharge a TIA patient for outpatient follow-up? How many of you can envision an ED doctor wanting to take the legal risks of writing that order? And, perhaps most important, how many of you can easily see yourself being cross-examined by Marty Malpractice, J.D., about why you ordered a TIA patient sent home who then suffered a massive stroke that night? All the literature supporting your position may not make you look good in those circumstances.
The only way I actually see this working out is with a national set of solid guidelines telling us to do this and tort reform to help protect the doctors who follow them. And let’s face it, neither is likely to happen in my lifetime.