This week I was in the General Respirology clinic and had the opportunity
to see a number of patients with obstructive lung disease. There were a variety of pathologies including
asthma, chronic obstructive pulmonary disease (COPD), asthma-COPD overlap
syndrome (ACOS), and alpha-1 antitrypsin (AAT) deficiency leading to COPD. Before seeing patients, they were each
evaluated in the pulmonary function lab with full pulmonary function testing
(PFT’s).
As a team, we were reflecting on the fact that several patients who have
never had formal PFT’s may be labelled as COPD patients. As a team, we were discussing that it would
be fruitful to have spirometry upfront when patients present to hospital in the
Emergency Department with respiratory distress.
That would be feasible given that we have respiratory therapists that can
perform this for us on-call. One
downside is that if spirometry is performed when patients are acutely unwell
then it may not be a marker of their best performance. However, the benefits would be that having
spirometry both at the beginning of admission and after admission for
comparison would aid in assessing whether there is reversibility or improvement
in their lung function. Another consequence
of not having a sense of a patient’s lung function upfront is that patients may
be treated for an exacerbation of COPD but may not in fact have obstructive
lung disease. The average overall cost
of a severe AECOPD is $9,557 given that it includes a hospitalization. (Mittmann
et al., 2008) Therefore, if we can determine with early spirometry that a patient
does not truly have obstructive lung disease, this can minimize their cost of
inhalers and hospitalizations. The cost
of obtaining spirometry is less than $100.
(Choosing Wisely, 2014)
On the other hand, resource management also includes being judicious
when ordering tests that may be expensive when the index of suspicion of a
certain pathology is low. For example, a
sleep study is an expensive test and the American Association of Sleep Medicine
and the American Board of Internal Medicine released guidelines on five things
to know before ordering polysomnography and for treating sleep disorders. (Choosing
Wisely, 2014)
At the Yale University School of Medicine, a session in the format of
Morning Report was implemented to demonstrate the costs associated with work-up
of clinical cases. (Fogerty et al.,
2014) The session was found to be useful in learning the impact of medical
decision-making and promoting more realistic clinical work-up. (Fogerty et al., 2014) The importance of learning
about resource management is a topic that I have had the chance to reflect on
throughout my selective. We work in a
system with a finite number of resources and it essential to appropriately order
tests given their cost and utility and consider such factors in addition to
your clinical assessment when making decisions.
SH
Resources:
Mittmann, N., Kuramoto, L., Seung, S.J., Haddon,
J.M., Bradley- Kennedy, C. & Fitzgerald, J.M. (2008). The cost of moderate
and severe COPD exacerbations to the Canadian healthcare system. Respiratory
Medicine, 102, 413-421. Retrieved at http://www.resmedjournal.com/article/S0954-6111(07)00432-5/pdf
Choosing Wisely. (2014).
Spirometry for Asthma. Choosing Wisely,
An initiative of the ABIM Foundation. Retrieved at http://www.choosingwisely.org/patient-resources/spirometry-for-asthma/
Accessed on March 1, 2018
Robert L. Fogerty ,
Jason J. Heavner , John P. Moriarty , Andre N. Sofair & Grace Jenq (2014)
Novel Integration of Systems-Based Practice Into Internal Medicine Residency
Programs: The Interactive Cost- Awareness Resident Exercise (I-CARE), Teaching and
Learning in Medicine: An International Journal, 26:1, 90-94, DOI:
10.1080/10401334.2013.857338
Choosing Wisely. (2014). American Academy of Sleep Medicine: Five
Things Physicians and Patients Should Question. Choosing
Wisely, An initiative of the ABIM Foundation. Retrieved at http://www.choosingwisely.org/societies/american-academy-of-sleep-medicine/
Accessed on March 1, 2018
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