A little peek into the challenges of cost control

A MedPage Today post by what appears to be an informed consumer (and not a health care professional) provides a little peek into the factors that affect health care quality and cost. In Arriving at the ED, the author tries to figure out how she'd like to be transported to the emergency department if she thought she were having a heart attack. Since the hospital is a quarter mile away her inclination is to get there on her own or have a neighbor take her. But after reading the research and adding her anecdotal experience, she's not sure what to do.She cites a study demonstrating that it's better for patients with suspected heart attack to arrive by ambulance. The researchers show that when patients arrive by ambulance they are likely to get faster treatment, whether measured by door to cath team activation, door to cath lab, or door to balloon. The key factor the researchers focused on was the use of EKG in the ambulance, which gave the ED team a head start on diagnosis once the patient arrived.But the author has in the back of her mind a competing explanation:

I know that even on a quiet Tuesday evening with nothing particular going on, you may find a great crowd of the sore, sick, lame, and disabled encamped there, all waiting for attention.

And on a busy, summer holiday weekend, forget about it.

I took my husband there once on the Fourth of July. Victims were streaming in from nearby parks and picnic grounds. The sun-poisoned, the bleeding, and those burned by charcoal grills packed the ED. Children climbed around on the plastic seats. Food was smuggled in from picnic coolers or fast food places down the road. Tempers flared as the wait dragged on. Busy staffers rushed back and forth.

Now, if I were to appear with my heart attack symptoms amid such a hubbub – short of my crumpling dramatically to the floor – would anyone notice me?

If I were her I would probably call the ambulance, even though they probably wouldn't have time to do an EKG on such a short trip. And as a society we have to watch out for the cost and quality implications of patients starting to realize what a messy process the health care system is. We look for "patient engagement" as a key element of health care quality improvement, but what if it results in patients engaging in behaviors that are more costly to the system or disruptive?