Published in the November 2013 issue of Today’s Hospitalist
WHEN THE PATIENT WENT INTO THE HOSPITAL for an acute problem, his hypertension wasn’t an issue. But when he saw Michael A. Steinman, MD, in an outpatient clinic after discharge, he was lightheaded and had low blood pressure. Dr. Steinman, who works as both a hospitalist and outpatient physician for the University of California, San Francisco, and the San Francisco VA Medical Center, easily figured out why just by looking at the discharge summary: The inpatient physicians had waded deep into chronic disease management without knowing the patient’s full story.
This wasn’t the first time Dr. Steinman had seen this problem, particularly in patients with high blood pressure or diabetes. He decided to air the issue in a commentary posted online in August by JAMA Internal Medicine.
According to Dr. Steinman, hospitalists are exercising a well-intentioned reflex to do the right thing. But he thinks they need to temper the quick responses valued in inpatient settings with a more complete picture of the patient’s long-term condition. This particular patient, for example, had well-controlled hypertension when he went into the hospital, and any elevation was from the stress of the hospital stay itself.
“Although the patient’s acute illness was resolved when he left the hospital, his blood pressure was in the tank because now he was on extra hypertensives,” Dr. Steinman says.
Practicing in both inpatient and outpatient settings gives him a good view of the problem and ways to fix it. “Here’s my advice: Unless the chronic disease has a direct impact on the reason for hospitalization, it’s often best not to start changing the patient’s medications,” Dr. Steinman says. “In other words, ‘Don’t just do something “stand there.'”
He talked to Today’s Hospitalist about why hospitalists should reframe how they view their role in handling chronic disease.
Why are hospitalists getting it wrong with these patients?
There are no data on this, but I suspect that hospitalists are treating a number such as blood pressure or serum glucose, rather than appreciating how that number relates to the patient’s overall situation. In a hospital, these kinds of parameters can get out of whack. But unless it’s harming the patient’s acute health, in most cases it doesn’t make sense to modify therapy.
What are some examples?
A patient’s blood pressure being greater than 140 may be misinterpreted as uncontrolled hypertension that needs increased medication management. But that is guidance for the outpatient setting “except for malignant hypertension, which is an acute issue. It is a misplaced view in the hospital because patients’ blood pressure will go up when they’re in pain and stress and in an unfamiliar environment. But that’s not the same thing as hypertension and shouldn’t be treated as such.
Diabetes is another disease where there tends to be a focus on a number, the blood glucose. The perception is often that a high number is bad and should be managed, but in most cases it has little impact on the patient’s short-term health. If glucose-lowering therapy is intensified, patients are at risk of becoming hypoglycemic once they return home and the stress of acute illness has resolved.
So is this about reacting to numbers?
Not necessarily. It can also be about guidelines “that blood pressure or blood glucose should be below a certain number, or if you have a certain disease, you should be on these three medications. There’s good evidence that patients leave the hospital on substantially different regimens than they are taking when admitted. For hospitalists, it’s very easy to start a patient on a medication and send him on his way.
What happens when hospitalists intervene when they shouldn’t?
Inpatient physicians are applying a short-term fix to a long-term problem, but the long-term is what matters. The physician doesn’t always have a full understanding of the patient’s history. Maybe the patient didn’t tolerate a medication or adhere to a regimen. So the physician may be missing the mark and causing harm.
There’s also a high potential for patients to get confused about proper medication use, as well as how long to take those medications.
So instead of writing a prescription, what should hospitalists do?
The most efficient and effective role for a hospitalist in chronic disease management is to pick up the phone and call the outpatient physician. Then, clearly communicate to that physician through the discharge summary in a note to cue him or her that an issue came up.
Is it ever appropriate to address the chronic condition, even if it’s not part of the acute condition?
If a patient has heart failure and is not on medications, communicate that to the outpatient clinician. That physician might say, “Yes, start those medications in the hospital.” That can be a real win-win because you start the patient on a path for better therapy, and the outpatient physician is in the loop and has given you the context. Then focus patient education on the new medication to minimize confusion.
What if patients don’t have an outpatient physician?
Get them an outpatient physician. Or if they have one but don’t go because of costs, work with a social worker to help them get long-term outpatient care. That’s harder than writing a prescription, but ultimately it’s what helps a patient.
Is this problem more common among younger doctors?
Many residents are trained in silos of care where there’s less recognition of how things work in other settings. Doctors who’ve been around longer are more likely to have more outpatient experience. They may have a better visceral understanding of what’s going to happen when you send the patient home.
Won’t it be difficult for hospitalists to resist the urge to do something?
Yes, because it goes against our instincts and training. Part of the problem is recognizing the limitations of what an inpatient doctor can do for a chronic condition. Hospitalists can be less comfortable with sitting tight and doing nothing.
If you were trained by people who treat aggressively, it is the norm to think that this represents good care “which it is when managing acute disease, but often less so managing chronic disease. It’s hard to break this mindset. The fix has to be peer mentoring and creating normative values where a conservative approach to managing chronic-disease manifestations in the hospital is better tolerated.
What ultimately will affect this is a more integrated culture between the inpatient and outpatient settings.
What do you hope will happen by raising this issue?
I want to challenge the mindset and norms that have allowed this practice to flourish. If patients come to the hospital for pneumonia but have hypertension, treating the hypertension won’t make them get better any faster.
If you can improve an acute outcome by treating a chronic disease, by all means do it. But if the condition is not related to the hospital stay, take a step back and keep the patient’s big picture in mind. Often, the best thing we can do is to resist the temptation to change the medication regimen.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.