This chapter summary is written by Dr. Coyne. He is a Professor of Medicine in the Division of Nephrology at Washington University in St. Louis. He is the Medical Director of the Chromalloy American Kidney Center, one of the first dialysis centers in the US, and the Director of the Medical Multispecialty Clinics at Washington University. He has participated in trials of ESAs and IV iron products in patients with CKD or on dialysis since 1998, and was the lead investigator of the DRIVE trial examining the benefit of IV iron in hemodialysis patients with elevated Ferritin.
The Edifice Complex begins section three, The Impact. The previous chapters have outlined grandiose microchips and continuous patient readouts, limitless biome and genomic analyses, and seamlessly integrating this information into apps that diagnose, treat and manage disease. This chapter is the closest to addressing costs and it is remarkably short and very weak. It begins with the observation that cardiac catheterization has gone from a 3 day hospital stay to essentially an outpatient procedure, without a jump in technology, but low tech improvements which he calls “All analog stuff; nothing digital…”. If one stops to think, this doesn’t tell us about the need for hospitals or how to save money. Nephrology also saw a major shift in vascular access related hospital stays, which shifted from inpatient surgical procedures of 2-4 days duration to outpatient Interventional Radiology procedures. However, cardiac cath and vascular access procedures were supplanted by other types of stays, with the growth in BOTH inpatient and outpatient care and costs for cardiac and renal patients.
In Nephrology, infectious and cardiovascular hospital days increased during this time frame. Similarly, Cardiologists are not suffering from a lack of inpatients due to “analog changes in cardiac catheterization procedures”.
Topol then proceeds to note the reduction in hospitals in the US from 7,156 in 1975 to 4995 in 2013. He states as future fact “…hospitals, as we know them today, will eventually be extinct.” Yogi Berra said “Predictions are hard, especially about the future”. It is easy to make predictions about the future with qualifiers like “hospitals, as we know them today”, and “eventually”. If you dispute his claim tomorrow’s hospital is different, he points to “as we know them today”! If you dispute that, he says “eventually!”
Topol follows the introductive claim that hospitals will be extinct with the 1999 IOM report that 98,000 people die each year in the US die due to hospital related and preventable lethal (author’s italics) events. This highlights how dangerous hospitals are – and indeed they are and much should change about how we provide care and guard against errors. However, he doesn’t disclose how many people died each year in the US – it is 2.6 million – or how many do so outside the hospital from causes that could be preventable if they had been in a hospital. I am thinking it is more than 98,000. The seriousness of medical errors contributing to deaths shouldn’t lead to the conclusion we should get rid of hospitals any more than highway deaths should lead us to get rid of highways.
Topol highlights the cost of US hospital care and it is astounding, averaging $4,300/day, with hospital costs totaling $850 billion per year. We never learn what Topol’s grand empowered patient plan will cost, but he speculates it will be less than hospitals cost. Like shifts in cardiac caths and access procedures to outpatient care, a more prudent view would be Topol’s plan would just expand costs. Even shifts to the proposed “no outcome, no income” medical payment system which he mentions has serious downsides of pushing doctors to avoid high-risk patients.
Topol insists there is no need for hospitals in the future and this is how he will presumably pay for his plans. On page 190, he defends this claim by stating 57% of people in a large poll thought traditional hospitals will be obsolete in the future. Setting aside the fallacy of the majority, this ‘truth’ bends more on the definition of ‘traditional’ than ‘hospital’. He also supports this by claiming Montefiore built an entire hospital without beds! It sounds like an outpatient surgical center to me, and when I was in Montefiore last year, they had lots of beds.
Topol outlines how medical homes will scan patients with disease for deterioration, monitor the ill for changes in status, and alert doctors and nurses when help is needed. Two thoughts come to mind: 1. This sounds like an extended care facility or home health care to me. Patients go from those locations back to the hospital when they deteriorate, while Topol proposes the hospital go to them. 2. When seconds count to save grandma’s life, help is just 30 minutes away! More seriously, it is unclear how 5,000 hospitals are too expensive but tens of millions of medical homes monitoring patients will be cheaper. However, if it is cheaper, then let’s do it.