Hospital Patients are More Complicated Than Ever: What It Means for Medicine

Let’s face it. The practice of Medicine is just harder now.

The first time I saw a patient in the hospital was in 2004, twenty years ago, when I was a third-year med student.

Since that time, I have spent countless hours in the hospital as a resident, a renal fellow, and finally as an attending. And I’m sure many of you in the medical community feel the same thing I do – which is that patients are much more complicated now than they used to be. I’ll listen to an intern present a new case on rounds and she’ll have an assessment and plan that encompasses a dozen individual medical problems. Sometimes, I have to literally be like – wait, why is this patient here again?

But until now I had no data to convince myself that this feeling was real – that hospitalized patients are getting more and more complicated, or that they only seem more complicated because I’m getting older. Maybe I was better able to keep track of things when I was an intern rather than now as an attending, spending just a couple months of the year in the hospital. I mean, after all, if patients were getting more complicated, surely hospitals would know this and allocate more resources to patient care, right?

Right?

It’s not an illusion. At least not according to this paper, appearing in JAMA Internal Medicine, which examines about 15 years of inpatient hospital admissions in British Columbia. 

I like Canada for this study for two reasons. First – their electronic health record system is province-wide, so they don’t have issues of getting data from hospital A vs. hospital B. All the data is there – in this case more than 3 million non-elective hospital admissions from British Columbia. Second, there is universal healthcare. We don’t have to worry about insurance companies changing, or the start of a new program like the Affordable Care Act. It’s just a cleaner set up.

Of course, complexity is hard to define, and the authors here decide to look at a variety of metrics I think we can agree are tied into complexity. These include things like patient age, comorbidities, medications, frequency of hospitalization and so on. They also looked at outcomes associated with hospitalization- did the patient require the ICU, did they survive, were they readmitted?

And the tale of the tape is as clear as that British Columbian air – over the past 15 years, your average hospitalized patient is: about 3 years older, is twice as likely to have kidney disease, 70% more likely to have diabetes, is on more medications, particularly anticoagulants, and is much more likely to be admitted through the emergency room. They’ve also spent more time in the hospital in the past year.

Given the increased complexity, you might expect that the outcomes for these patients are worse than years ago, but the data does not bear that out. In fact, inpatient mortality is lower now than it was 15 years ago, although 30-day post-discharge mortality is higher. Put those together and it turns out that death rates are pretty stable – 9% of people admitted for non-elective reasons to the hospital will die within 30 days. It’s just that nowadays, we tend to discharge them before that happens.

Why are our patients getting more complex? Some of it is demographics – the population is aging, after all. Some of it relates to the increasing burden of comorbidities, like diabetes and kidney disease, which are associated with the obesity epidemic. But in some ways, we’re a victim of our own success. We have the ability to keep people alive today that would not have survived 15 years go. We have better treatments for metastatic cancer, less-invasive therapies for heart disease, better protocolized ICU-care.

Given all that, does it make any sense that many of our hospitals are at skeleton-crew staffing levels? That hospitalists report taking care of more patients than they ever have before?

There’s been so much talk about burnout in the health professions lately. Maybe something people need to start acknowledging – particularly those who haven’t practiced on the front lines for a decade or two – is that the job is, quite simply, harder now. As patients become more complex, we need more resources, human and otherwise, to care for them.

A version of this commentary first appeared on Medscape.com.