Walking in, walking out, walking about

Or, in honor of the Vancouver Olympics, "Walking a-boot".

Oh, Lordy. This post ended up being quite long, and quite possibly boring. Oops. Blame February.

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So today, we're going to discuss some things that I am trying to do some research about. (These posts never really get a huge comment response, but I persevere. Mostly because I want to graduate). Y'all can help, if you'd like. Then we can all graduate!*

This is one research project that I could really use your help with; I've been calling it the "Transience of Care" study when I talk to people (more on this name in a bit).

Remember these ladies? This experience - someone who shows up, in labor, with no prior prenatal care at our particular hospital - is a relatively common occurrence at my Big City Hospital.

This is a story told in many ways:
- Type A: I received prenatal care, but it was in a different city/country/continent and I don't have records
- Type A1: I recieved prenatal care, and ta-da! here are my records. 
(We love Type A1s. They are rare. Also: sometimes they don't give you records if you don't ask for them. Maybe there's a Type A1a - I have records, but they're in my purse, so you just repeated all my labs and you didn't need to and you should just learn to ask, so there.)
- Type B: I never received prenatal care, not anywhere.
- Type C: I've never gotten formal outpatient prenatal care at your institution, but I've been to triage so many times that it has become my de facto prenatal care site

and, what I believe is the most common (and most reviled by the nursing staff and residents):
- Type D: I recieved prenatal care. It was here in Large Urban Area, but I didn't like them/didn't know what hospital they were affiliated with/just called an ambulance for the closest hospital with my first contraction/was walking by/my mom said you guys were great/heard you have private rooms for postpartum patients.**

All of these patients, Types A-D, are called "walk-ins". You know: "Oh, you're admitting patient X for labor? Who's her doctor? Ah, she's a walk-in."

I happen to be all for patient options, and to be honest, I'm even ok with people voting with their feet (and Medicaid dollars) when they don't like their care.  Hurray for free markets!** HOWEVER. Walk-ins are killer on your staff. Why?

Well, for one thing, it is very hard to get 9 months worth of work done in one visit while actually admitting someone in labor, and that it leads to a large amount of hostility. However, the frustration associated with this kind of patient presentation is incredibly high. It's not just that the amount of work is resented; it seems to be something more painful than that. Perhaps it's how the entire walk-in approach seems to show that the patient doesn't really appreciate any of the work we do for its complexity or its importance or its cost. ("Oh, everything you did for my whole pregnancy can just be easily and painlessly reconstituted over the next hour.") I think there's also an element of perceiving the patient as either manipulative ("She is using MY tax dollars to come here because she doesn't like Other Hospitals bathrooms? Why is that fair?") or irresponsible ("Why didn't she get proper care, at one location, like you're supposed to? She is not fit to be a mother.").

What's going on here is not entirely clear. Although some of the patients are very, very savvy and manipulating the system for their own benefit and going all Milton Friedman on us, most are not. Most are unsophisticated and low on resources and really not terribly clueful about how to get good care. They don't know that there's a system, and a rhyme, and a reason. They didn't know that you're supposed to go somewhere specific for delivery; they didn't know that they were getting a particular type of good and consistent care. So they just show up and hope for the best. 

My idea was to study these patients, in comparison to patients with more conventional prenatal care. Like all research work, I have both some guesses and an agenda.

The guesses:
a) The walk-in group will demonstrate the receipt of suboptimal care and outcomes, although which outcomes I can usefully measure to demonstrate this is unclear.

Thankfully, most terrible outcomes are rare enough that to show a meaningful difference between transient care patients and usual care patients would require an ENORMOUS cohort. That is unlikely to happen; see above, re: desire to graduate.

So we will have to settle for less-than-ideal outcomes instead of horrific ones - c-sections, perhaps, or use of antibiotics, or longer-than-normal hospital stays, the rates of which I have a strong hunch will be higher in my walk-in population. Or NICU stay for the baby, because I think we don't always have either great dating or group B strep status on these patients.

b) I'm not sure what the cost-effectiveness will be, or whether is reasonable to think about measuring it. Why? Well, because, sadly, prenatal care has never been shown to be really cost-effective. This always depends on how you define both cost and effectiveness, because of course, the cheapest thing to do is to offer no care to anybody. But then, you know, people die, and somehow we all decide that that's not really what we wanted to accomplish. So we then get into long discussions, and the discussion ends up with talking about how to meaninfully measure what we did want to accomplish. And currently that measure is QALYs -Quality Adjusted Life Years. Meaning, we try to figure out how much more quality-of-life you get for how long (that's the effectiveness) per dollar (that's the cost). In the U.S., $50-100,000 per QALY is considered reasonable. 

My point of this was that even when using QALYs as a unit, prenatal care has never been shown to be cost-effective. But we all agree that prenatal care is a Good Thing (although the timing and amount can be debated). So it may just be that we have not figured out a way to calculate the Goodness of this Thing. However, although I'm sure Walk-Ins are more expensive than non-Walk-Ins, it's hard to demonstrate a lack of cost-effectiveness when even conventional prenatal care does not demonstrate cost-effectiveness. Is that clear at all?

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Those are my guesses. Here's my agenda.

I think I'd like to prove what I usually I tell these patients. Here is my little speech: I am happy to take care of you. You are always welcome here. But this is a bit of a waste, isn't it? You worked hard, for 9 months, to take care of yourself and your baby, and I can't use any of that hard work, because I do not have access to those records. We'll do the best we can today, and we won't let anything bad happen to you, but we've lost an opportunity. In the future, try to give yourself the advantage of all the effort you put in, and bring your records, or get your care at the same hospital unless you have a really good reason to leave.



Because y'all know I like to educate a bit before discharging people from triage. And, in the end, I want the walk-in patients to be smarter about how they get their care. So I'd like to prove to them that working with the system - going to the hospital that knows them - is actually to their benefit.

That being said, although I think the patient suffers slightly (and I think demonstrating this and making it an element of public knowledge is really the way to make it change), the true highest cost of the walk-in patient is probably that provider frustration that I discussed above. (And, as you can guess from this, that's an emotional decider, and thus something I am interested in.) However, I don't really know how to measure provider frustration, and I'm pretty convinced that even if I did, it's not a valued outcome; it wouldn't be something that would require a policy change. I'm going to leave that behind and stay with the more conventional outcomes, at least for now.

(We could, of course, argue that provider frustration/burnout/fatigue is somehow linked to poorer care. It probably is, on a subtle level; but my guess [and hope!] would be that, as professionals, this low-level frustration doesn't generally lead to terribly different outcomes on an individual patient basis.)

All right. So that's that. Remember, please, that I have a very limited public health background, so if I've gotten something wrong about QALYs or other stuff, please correct me in the comments.

But now we've come to your job. Here's how you can help. The first step to all good research is to look at what's already been done, i.e. the literature review; both so you don't replicate it, and so you know how people are talking about this.

So far, I have tried the following in order to produce a literature review:
- prenatal care patterns
- prenatal care utilization
- (delivery) (prenatal care) site OR location OR center OR hospital
- transient prenatal care
- fragmented prenatal care

- every conceivable combination of the above

Very few results have returned, and none dealing with my "Walk-In" problem.

This is either because
a) I am a genius! I have diagnosed a new social problem and now I have the field all to myself
OR
b) I am an idiot and I cannot find the five-hundred papers written on this problem already because I don't know the right terms.

I am highly suspicious that the answer is "b". Part of my suspicion arises from the fact that this seems very closely related to a Hot Topic right now, which is the universal electronic medical record much debated in policy analysis and politics. You know this idea, the one where we're going to save bazillions of dollars because doctors will be able to get all your results from some giant computer system rather than re-doing all your care? Doesn't that sound somewhat adjacent to my walk-in research? Thus, must be much-discussed. Therefore, can anyone out there tell me what the proper search terms are?^

Also, do you think this is interesting? Clearly, this is a very geographically limited problem - it's only going to be an issue in large cities, for example, with multiple available hospitals with obstetric services. So, is this just about my life? Or something larger?



*I will make room for everybody on my diploma, not to worry. 
**This classification system was just invented while writing this post, and needs work, particularly because you can be a Type C and a Type A/B/D.I thnk instead, I will need to divide it out into two axes: care provided and care documented. Thus, Axis 1: what kind of care did you receive and where? And Axis 2: Do we have access to the records of that care?
***Sorta. Really, because of all the Medicaid, arguably neither free nor a market. But still: a mention for the Bearded Economist, for whom my general misuse of this term is actually physically painful. Heh heh. 
^Got tired of counting asterisks. I already asked my Facebook friends for suggestions. Useless, that lot. (Not really. They tried; that's where I got some of the terms above.) But I have high hopes of you.