I can feel Brian’s presence hovering over me before he speaks and I know what’s coming. He’s fielded a call from a dialysis patient we take care of and there’s an issue with their fistula. It may be high pressures, or the dialysis center reporting that they’re “pulling clots,” or the fistula is thrombosed. In this case, it turns out to be the latter. The thrill is gone. The patient was eating a Snickers bar while on the phone with Brian and that answers the scheduling questions. We return the patient’s call and tell him to come to our office based lab (OBL) in the morning and we can take care of the problem.
He showed up in our waiting room an hour before his procedure. A few hours later he was home with a buzzing in his left arm. Doing this at the hospital would require a visit to the emergency department and an overnight stay in the hospital. The case would be an add on and be at the whim of emergencies and surgical delays. Posting it as an outpatient case is technically possible but impractical in reality. In a world of block time and scheduling efficiency, finding time to insert an outpatient case is a formidable challenge.
Beyond the efficiency and convenience, there is a cost savings for the health care system. Despite the push for site neutrality, there remains a significant gap between reimbursement for these procedures in an OBL or ambulatory surgery center (ASC) compared to the hospital outpatient setting. This only tells a partial story. The complete story would also include the costs of emergency department visits and inpatient stays. I was well acquainted with the gentleman Brian told me about that afternoon. A dialysis access that starts acting up isn’t going to start behaving after one intervention. These issues can become relatively frequent and the costs add up across a large patient population. The alternative, abandoning the access, is untenable. A functioning access is a literal lifeline and giving one up brings the patient one step closer to running out of options.
We tend to get lost in the minutiae of the pros and cons and these are pertinent discussions. It’s relevant that these procedures can be done safely and at lower cost in the outpatient setting compared to the hospital. Moving these lower acuity cases to an OBL or ASC, away from the more complex cases that need hospital resources, is efficient. However, these points miss the bigger story. Our dialysis patients live highly medicalized lives. They spend a combined half a day of their waking hours every week watching blood flow in and out of mechanical filters. The hours and days we save them by avoiding the complexity of navigating the hospital every time their access misbehaves are priceless.
